Maternal Mortality In Low-income Countries Research Articles

MISOPROSTOL AS PREVENTION OF POSTPARTUM HEMORRHAGE: A TEN YEARS SYSTEMATIC REVIEW

Background: Postpartum Haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth. PPH is the leading cause of maternal mortality in low-income countries and the primary cause of nearly one quarter of all maternal deaths globally. The aim: This study aims to show about misoprostol as prevention of postpartum hemorrhage. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 23 articles, whereas the results of our search on SagePub brought up 39 articles. The results of the search conducted for the last year of 2014 yielded a total 13 articles for PubMed and 27 articles for SagePub. The result from title screening, a total 5 articles for PubMed and 14 articles for SagePub. In the end, we compiled a total of 10 papers. We included five research that met the criteria. Conclusion: Other injectable uterotonics and misoprostol are recommended as alternatives for the prevention of PPH in settings where oxytocin is unavailable.

A Ketamine Package for Use in Emergency Cesarean Delivery When No Anesthetist is Available: An Analysis of 401 Consecutive OperationsAnesthesia and AnalgesiaAnesthesia and Analgesia

(Int J Gynecol Obstet. 2022;158:377–384) Average maternal mortality in low-income countries has been reported as 40 times higher than that of high-income countries. One contributing factor to this discrepancy is the shortage of surgical care either due to inaccessible resources or inaccessible clinicians such as anesthesiologists. There is a particularly noticeable gap in anesthesiology care, as most low-income countries do not have anesthesiology training programs, or the programs do not produce enough clinicians to fully staff what is needed. This study aimed to understand the implications of using ketamine as an anesthetic to support emergency surgical delivery if no anesthetist is available. Effectiveness and safety was evaluated through maternal and newborn outcomes. The primary outcome was maternal and infant survival, and the ability of ketamine to safely support cesarean deliveries (CD).

The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia

BackgroundPostpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions.MethodsBetween August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and “health extension workers,” 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario.ResultsBaseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2–35.1 compared to 1·8; 95% CI – 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3–18.3 compared to 3.1; 95% CI – 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0–15.0).ConclusionThe Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality.Trial registration: Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.

Determinants of Antenatal Care Access and Utilization in Haiti

Several pregnancy-related complications resulting in maternal mortality in low-income countries may be due to inaccessible or under-utilized antenatal healthcare services. This study aims to assess the sociodemographic characteristics of Haitian women and how these may affect their access to and use of antenatal care services (ANC) during pregnancy. Multi-logistic regression was used to analyze sociodemographic factors associated with ANC access and use among a cross-section of Haitian women (N = 4890) from the Demographic and Health Survey Haiti (2016–2017). Approximately 18.2% of the women had no education, 40.2% had secondary education, and 4.0% had higher education. About 45.6% of women with no education, 95% with higher education, and 76% of urban dwellers made four or more ANC visits. Only 3% of those who used public sector ANC had a higher education, and over 64.2% of those who used private sector ANC lived in urban areas. Rich women (OR = 2.49, 95% CI = 2.02–3.08) vs. poor women and mature mothers (OR = 1.97, 95% CI = 1.42–2.73) vs. teenage mothers both had higher odds of using ANC services four or more times. Women with higher education (OR = 0.19, 95% CI = 0.12–0.30) and those who were rich (OR = 0.67, 95% CI = 0.5–0.89) had lower odds of using public sector ANC vs. private sector ANC. Wealth and education are protective of ANC access and use by Haitian women. As over half the population has home births, public health education interventions targeting traditional birth attendants are recommended. Interventions training traditional birth attendants to provide better ANC during pregnancy and at the time of birth and to access skilled help during emergency deliveries is recommended.

Postpartum hemorrhage management according to the underlying cause

Postpartum hemorrhage (PPH) is still a significant cause of death worldwide. This condition is classically defined as a blood loss of 500 ml or more within 24 hours after birth. Their most common causes are uterine atony, placental retention, coagulation disorders or genital trauma, and the management depends on each cause. PPH remains the leading cause of maternal mortality in low-income countries and stands out as the primary cause of nearly one quarter of all maternal deaths globally. Most deaths resulting from postpartum hemorrhage take place during the first 24 hours after birth, and the majority of these could be prevented through prophylactic uterotonics during the third stage of labor and by timely and appropriate management. Postpartum hemorrhage can occur in patients without priorly known risk factors for bleeding. The proper management of postpartum hemorrhage implies rapid diagnosis and treatment. The four Ts mnemonic can be used to diagnose and cure the four most common causes of postpartum hemorrhage: uterine atony (Tone); laceration, hematoma, inversion, rupture (Trauma); retained tissue or invasive placenta (Tissue); and coagulopathy (Thrombin). Fast-diagnosing team-based care significantly reduces the morbidity and mortality associated with postpartum hemorrhage, no matter the cause. This article plans to provide a scheme for the strategic policy and steps needed to ensure effective interventions in all PPH cases.

Tuberculosis and Sexual and Reproductive Health of Women in Four African Countries.

Tuberculosis (TB) is a major reason of maternal mortality in low-income countries, and it increases the probability of adverse sexual and reproductive health (SRH) outcomes, including ectopic pregnancy and perinatal mortality. The data presented here is from the TB Sequel observational cohort conducted in four African countries. For this sub-study, we selected only female participants, who were diagnosed with drug susceptible TB and followed-up until the end of anti-TB treatment. The data collection included questionnaires, clinical examination and laboratory tests at TB diagnosis, day 14, month 2, 4 and 6. A total of 486 women, with 88.3% being 18-49 years old, were included in the analysis. Around 54.7% were HIV positive. Most of the participants (416/486; 85.6%) in our cohort were considered cured at month 6. Only 40.4% of non-pregnant women of reproductive age used contraception at TB diagnosis. A total of 31 out of 486 women experienced pregnancy during TB treatment. Pregnancy outcomes varied between live birth (16/31; 51.6%), induced abortion (6/31; 19.4%), miscarriage (4/31; 12.9%) and stillbirth (3/31; 9.6%). Integration and linking of SRH services with TB programmes are vital to increase contraception use and protect women from obstetric risks associated with pregnancy during TB treatment.

Agenda setting and socially contentious policies: Ethiopia’s 2005 reform of its law on abortion

BackgroundIn 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion.MethodsThis retrospective case study describes the actors and processes involved in Ethiopia’s reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide information about context, process, or mechanism and can contribute to causal inference) and careful description and sequencing of factors in order to describe a novel political phenomenon and evaluate potential explanatory hypotheses.ResultsThe analysis of key actors and policy processes indicates that the ruling party and its receptiveness to reform, the energy of civil society actors, the “open windows” offered by the vehicle of the Penal Code reform, and the momentum of reforms to improve women’s status, all facilitated liberalization of law on abortion. Results suggest that agenda setting theories focusing on national actors—rather than external causes—better explain the Ethiopian case. In addition, the stronger role for government across areas of policy work (policy specification and politics, mobilization for enactment and for implementation), and the collaborative civil society and government policy relationships working toward implementation are largely internal, unlike those predicted by theories focusing on external forces behind policy adoption.ConclusionsEthiopia’s policymaking process can inform policy reform efforts related to abortion in other sub-Saharan Africa settings.

Postpartum Hemorrhage in Pregnancy beyond 40 Weeks of Gestation in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Postpartum hemorrhage is defined as a blood loss of 500ml or more within 24 hours after birth. It is the leading cause of maternal mortality in low-income countries and the primary cause of nearly one-quarter of all maternal deaths globally. It occurs in up to 18% of total births. Post-dated pregnancy is a high-risk pregnancy with increased maternal morbidity. This study aims to determine the prevalence of postpartum hemorrhage in pregnancy beyond 40 weeks of gestation in a tertiary care hospital. A descriptive cross-sectional study was conducted among pregnant women beyond 40 weeks in Dhulikhel hospital from October 2016 to March 2017. The study was conducted after ethical clearance from the hospital research committee (reference number#128/16). The sample size was calculated and convenient sampling was done. Statistical Package for the Social Sciences is used for analysis. Point estimate at 95% confidence interval was calculated along with frequency and percentage for binary data. Out of 465 ladies enrolled in this study postpartum hemorrhage was seen in 6 (1.29%) (95% Confidence Interval = 0.267-2.31), and the mean age was 24.25+4.8. About 346 (74.4%) had a normal delivery, 104 (22.36%) had cesarean section and 15 (3.22%) had instrumental delivery. Postpartum haemorrhage prevalence is low among the pregnant women beyond 40 weeks compared to the standard study. Postpartum hemorrhage is the common leading cause of maternal mortality. So high-risk cases should be identified and active management should be done to reduce morbidity and mortality.

Barriers inhibiting effective detection and management of postpartum hemorrhage during facility-based births in Madagascar: findings from a qualitative study using a behavioral science lens

BackgroundPostpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers’ consistent following of PPH best practices in Madagascar.MethodsIn June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts.ResultsWe identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers’ perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making.ConclusionsOur study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.

Preventing post-partum haemorrhage at home during COVID-19: what are we waiting for?

Preventing post-partum haemorrhage at home during COVID-19: what are we waiting for?

Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries.

Some countries reached, in 2015, the Millennium Development Goal of reducing maternal mortality to 96 or less maternal deaths per 100,000 live births. Others, however, did not. This paper analyses the strength of the association between maternal mortality and each of the six components of Governance-a political determinant scarcely explored in the literature-in 174 countries. It was found that the greater the governance, the lower maternal mortality, independently of a country's wealth. We used all six indicators of the World Bank's Worldwide Governance Indicators Project in 2015: government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence. Findings were encouraging as maternal mortality in low-income countries with higher government effectiveness and regulatory quality was similar to that of medium-income countries with lower government effectiveness and regulatory quality. To achieve the post-2015 sustainable development goal on preventable maternal mortality-which persists despite economic development-all governance dimensions are essential and represent interdependent cornerstones.

Heat-Stable Carbetocin Could Replace Oxytocin To Prevent Postpartum Haemorrhage Following Vaginal Delivery

Postpartum haemorrhage (PPH) is the most common type of obstetric haemorrhage and accounts for 35% of all maternal deaths. World Health Organisation (WHO) defines PPH as: blood loss of 500 mL or more within 24 hours following vaginal delivery. PPH is the leading cause of maternal mortality in low-income countries, and the primary cause of nearly one quarter of all maternal deaths globally. Uterine atony is the most common cause of PPH accounting for more than 80% of causes. Thus, to prevent PPH, WHO has recommended active management of third stage of labor. All women giving birth should be offered uterotonics during the third stage of labor (as a part of third stage management) for the prevention of PPH; oxytocin (IM/IV, 10 IU) is recommended as the uterotonic drug of choice.
 
 Conclusion: Heat stable carbetocin can be a breakthrough drug for overcoming heat degradation of oxytocin. Cold chain for storage or transportation of uterotonic drug is thus now not an issue. This single advantage can remarkably reduce the morbidity and mortality in low-income countries due to PPH as this drug can be made available even in most remote part of the country. Heat-stable carbetocin was studied aiming the developing countries. We can hope to see this drug in the new update in WHO recommendation for prevention of postpartum hemorrhage; that undoubtedly would be a very remarkable change, especially for resource limited countries like ours.

Active versus expectant management for women in the third stage of labour.

Active versus expectant management for women in the third stage of labour.

Medical society engagement in contentious policy reform: the Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia's 2005 reform of its Penal Code on abortion.

Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have reformed their laws to permit safer, legal abortion, and professional medical associations have not tended to spearhead this type of reform. Support from a professional association typically carries more weight than does that from an individual medical professional. However, theory predicts and the empirical record largely reveals that medical associations shy from engagement in conflictual policymaking such as on abortion, except when professional autonomy or income is at stake. Using interviews with 10 obstetrician–gynaecologists and 44 other leaders familiar with Ethiopia’s reproductive health policy context, as well as other primary and secondary sources, this research examines why, counter to theoretical expectations from the sociology of medical professions literature and experience elsewhere, the Ethiopian Society of Obstetricians & Gynecologists (ESOG) actively supported reform of national law on abortion. ESOG leadership participation was motivated by both individual and ESOG’s organizational commitments to reducing maternal mortality and also by professional training and work experience. Further, typical constraints on medical society involvement in policymaking were relaxed or removed, including those related to ESOG’s organizational structure and history, and to political environment. Findings do not contradict theory positing medical society avoidance of socially conflictual health policymaking, but rather identify how the expected restrictions were less present in Ethiopia, facilitating medical society participation. Results can inform efforts to encourage medical society participation in policy reform to improve women’s health elsewhere in sub-Saharan Africa.

Prevalence and risk factors for maternal mortality in referral hospitals in Nigeria: a multicenter study.

IntroductionWhile reports from individual hospitals have helped to provide insights into the causes of maternal mortality in low-income countries, they are often limited for policymaking at national and subnational levels. This multisite study was designed to determine maternal mortality ratios (MMRs) and identify the risk factors for maternal deaths in referral health facilities in Nigeria.MethodsA pretested study protocol was used over a 6-month period (January 1–June 30, 2014) to obtain clinical data on pregnancies, births, and maternal deaths in eight referral hospitals across eight states and four geopolitical zones of Nigeria. Data were analyzed centrally using univariate, bivariate, and multivariate statistics.ResultsThe results show an MMR of 2,085 per 100,000 live births in the hospitals (range: 877–4,210 per 100,000 births). Several covariates were identified as increasing the odds for maternal mortality; however, after adjustment for confounding, five factors remained significant in the logistic regression model. These include delivery in a secondary health facility as opposed to delivery in a tertiary hospital, non-booking for antenatal and delivery care, referral as obstetric emergency from nonhospital sources of care, previous experience by women of early pregnancy complications, and grandmultiparity.ConclusionMMR remains high in referral health facilities in Nigeria due to institutional and patient-related factors. Efforts to reduce MMR in these health facilities should include the improvement of emergency obstetric care, public health education so that women can seek appropriate and immediate evidence-based pregnancy care, the socioeconomic empowerment of women, and the strengthening of the health care system.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Composite measures of women\u2019s empowerment and their association with maternal mortality in low-income countries

BackgroundMaternal mortality has declined significantly since 1990. While better access to emergency obstetrical care is partially responsible, women’s empowerment might also be a contributing factor. Gender equality composite measures generally include various dimensions of women’s advancement, including educational parity, formal employment, and political participation. In this paper, we compare several composite measures to assess which, if any, are associated with maternal mortality ratios (MMRs) in low-income countries, after controlling for other macro-level and direct determinants.MethodsUsing data from 44 low-income countries (half in Africa), we assessed the correlation of three composite measures – the Gender Gap Index, the Gender Equity Index (GEI), and the Social Institutions and Gender Index (SIGI) – with MMRs. We also examined two recognized contributors to reduce maternal mortality (skilled birth attendance (SBA) and total fertility rate (TFR)) as well as several economic and political variables (such as the Corruption Index) to see which tracked most closely with MMRs. We examined the countries altogether, and disaggregated by region. We then performed multivariate analysis to determine which measures were predictive.ResultsTwo gender measures (GEI and SIGI) and GDP per capita were significantly correlated with MMRs for all countries. For African countries, the SIGI, TFR, and Corruption Index were significant, whereas the GEI, SBA, and TFR were significant in non-African countries. After controlling for all measures, SBA emerged as a predictor of log MMR for non-African countries (β = –0.04, P = 0.01). However, for African countries, only the Corruption Index was a predictor (β = –0.04, P = 0.04). No gender measure was significant.ConclusionsIn African countries, corruption is undermining the quality of maternal care, the availability of critical drugs and equipment, and pregnant women’s motivation to deliver in a hospital setting. Improving gender equality and SBA rates is unlikely to reduce MMR in Africa unless corruption is addressed. In other regions, increasing SBA rates can be expected to lower MMRs.

Prognostic factors of maternal near miss events and maternal deaths in a tertiary healthcare facility in India

To study maternal near miss (MNM) and maternal mortality to identify rectifiable risk factors. The present cross-sectional retrospective study included pregnant women who experienced acute life-threatening pregnancy-related adverse events at Deen Dayal Upadhyay hospital, New Delhi, India, between September 1, 2009, and August 31, 2011. Patient data were analyzed to investigate factors associated with MNM events and maternal deaths. There were 369 patients included, and 302 MNM events and 67 maternal deaths were recorded. The recorded causes of MNM events included hemorrhage, hypertensive disorders, severe anemia with cardiac failure, organ failure, and infection in 192 (63.6%), 62 (20.5%), 13 (4.3%), 8 (2.6%), and 8 (2.6%) patients, respectively. Higher rates of anemia (P=0.007) and infection (P=0.007) were recorded among patients in the maternal death group than the MNMN group. Hemorrhage and hypertension were major causes of MNM events and are likely major barriers to reducing maternal mortality in low-income countries. Anemia and infection were significant prognostic factors of maternal death in the present study. MNM could be used as surrogate for maternal death in the provision of standard obstetric care.

Stability of oxytocin along the supply chain: A WHO observational study

Postpartum haemorrhage is the leading cause of maternal mortality in low-income countries and oxytocin is the drug recommended by WHO for preventing and treating it. There are concerns about the quality of oxytocin available at the service level provider. The study aimed to document how temperature variations along the supply chain affect quality of oxytocin. The study was run from March to June 2015 in four regions of Ghana. 130 ampoules of oxytocin were shipped from the manufacturer to service level following Ghanaian public sector supply chain. Along the supply chain, temperatures were recorded continuously. After one month storage at central, regional and service level, ampoules were sent to laboratory for testing. Quality of the initial oxytocin sample from the manufacturer and the 130 oxytocin samples received from study points were tested according to International Pharmacopeia monograph. Samples fully complied with specifications. Temperature profile showed that the lowest and highest temperatures experienced were −9.9 °C and +30.1 °C. The results of this study indicate that the activity of oxytocin was not affected by these temperature excursions which occurred along the supply chain. The quality of the oxytocin from the manufacturer as well as from the service level was within the required specifications.

The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis.

BackgroundInequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services.MethodsA mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries’ education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women’s decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants.ResultsWomen with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home.ConclusionsTo improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as giving women insurance cards only does not guarantee facility-based delivery.