Skilled Birth Assistance Research Articles

Understanding Socioeconomic Inequalities in Zero-Dose Children for Vaccination in Underserved Settings of Ethiopia: Decomposition Analysis Approach.

Despite considerable global efforts to enhance vaccine distribution in low-income countries, a significant number of children remain unvaccinated, particularly in Ethiopia. The underlying socioeconomic challenges in these regions are recognized as primary contributors to the low vaccination rates. However, the reasons for this persistent disparity in Ethiopia's remote and underserved regions need further analysis. The study employed a cross-sectional design and was conducted as part of the Project HOPE Zero-Dose Evaluation from 1 February to 31 July 2022. Concentration indices were utilized to quantify the extent of inequality, with further decomposition aimed at identifying contributing factors to this disparity. The findings underscored that populations with lower socioeconomic status encounter high numbers of children receiving no vaccinations. Key factors influencing the number of zero-dose children included distance from healthcare facilities (61.03%), economic status of the household (38.93%), absence of skilled birth assistance (20.36%), underutilization of antenatal care services (<four visits; 8.66%), lack of postnatal care (8.62%), and rural residency (7.69%). To reduce the number of zero-dose children in Ethiopia, it is essential to implement context-specific strategies that address socioeconomic barriers and integrate innovative approaches with community engagement. This approach will help to ensure equitable access to vaccines for children across all socioeconomic statuses.

Utilizing maternal healthcare services: are female-headed households faring poorly?

BackgroundUtilization of maternal healthcare services has a direct bearing on maternal mortality but is contingent on a wide range of socioeconomic factors, including the sex of the household head. This paper studies the role of the sex of the household head in the utilization of maternal healthcare services in India using data from the National Family Health Survey-V (2019–2021).MethodsThe outcome variable of this study is maternal healthcare service utilization. To that end, we consider three types of maternal healthcare services: antenatal care, skilled birth assistance, and postnatal care to measure the utilization of maternal healthcare service utilization. The explanatory variable is the sex of the household head and we control for specific characteristics at the individual level, household-head level, household level and spouse level. We then incorporate a bivariate logistic regression on the variables of interest.Results24.25% of women from male-headed households have complete utilization of maternal healthcare services while this proportion for women from female-headed households stands at 22.39%. The results from the bivariate logistic regression confirm the significant impact that the sex of the household head has on the utilization of maternal healthcare services in India. It is observed that women from female-headed households in India are 19% (AOR, 0.81; 95% CI: 0.63,1.03) less likely to utilize these services than those from male-headed households. Moreover with higher levels of education, there is a 25% (AOR, 1.25; 95% CI: 1.08,1.44) greater likelihood of utilizing maternal healthcare services. Residence in urban areas, improved wealth quintiles and access to healthcare facilities significantly increases the chances of maternal healthcare utilization. The interaction term between the sex of the household head and the wealth quintile the household belongs to, (AOR, 1.39; 95% CI: 1.02, 1.89) shows that the utilization of maternal healthcare services improves when the wealth quintile of the household improves.ConclusionThe results throw light on the fact that the added expenditure on maternal healthcare services exacerbates the existing financial burden for the economically vulnerable female-headed households. This necessitates the concentration of research and policy attention to alleviate these households from the sexual and reproductive health distresses.Trial RegistrationNot Applicable.JEL ClassificationD10, I12, J16.

Appraisal of universal health insurance and maternal health services utilization: pre- and post-context of the Jaminan Kesehatan Nasional implementation in Indonesia.

The Indonesian government introduced universal health insurance through the National Social Security System (JKN) in 2014 to enhance overall healthcare. This study compares maternal health care (MHC) service utilization before and after JKN implementation in Indonesia. Using 2012 and 2017 data from Indonesia Demographic and Health Surveys (DHS), we conducted a two-period cross-sectional design study following the Anderson model. We assessed how the JKN policy and population characteristics influenced healthcare utilization for women aged 15-49 who had given birth in the last 5 years. Multivariable logistic regression models were used to assess the impact of the JKN policy and related factors. In two waves of Indonesia DHS with 14,782 and 15,021 subjects, this study observed a significant increase in maternal healthcare service utilization post-JKN implementation. Women were more likely to have at least four antenatal care visits (adjusted odds ratio, AOR = 1.17), receive skilled antenatal care (AOR = 1.49), obtain skilled birth assistance (AOR = 1.96), and access facility-based delivery (AOR = 2.45) compared with pre-JKN implementation. This study revealed a significant positive impact of JKN on enhancing MHS utilization. The introduction of universal health insurance coverage likely reduced financial barriers for specific demographics, resulting in increased service utilization. Our study may offer valuable insights for Asian countries with similar demographics and health insurance implementations.

Assessment of utilisation of government programmes and services by pregnant women in India.

Since the implementation of various maternal health programs, Maternal Mortality Ratio (MMR) has significantly declined in India through improvements in maternal health services. However, inequality persists at the regional and socio-economic levels. In light of this, the present study aims to assess the existing regional disparities in utilising various government initiatives for safe motherhood in India. National-level datasets such as National Family and Health Surveys (NFHS-3 (2005-06); NFHS-4 (2015-16) and NFHS-5(2019-21); Health Management Information System (HMIS), 2019-20; Sample Registrar System (SRS), 2001-2018) were used in the study. In addition, composite Index and inequality measures (Range, Ratio, and Gini) were calculated to examine inequality. At the same time, the Pearson correlation was used to investigate the correlation between various components of maternal health services and Maternal Mortality Rate (MMR). The composite index score (0.65) reflects that India is still far behind the targets of the utilisation of maternal health care services. Within the utilisation of services, the Gini coefficient reveals that the least inequality was recorded in skilled birth assistance deliveries (0.03) and institutional deliveries (0.04). In contrast, the highest inequality was recorded in receiving Iron and Folic Acid (IFA) Tablets for 100 days (0.19) and four Antenatal Care (ANC) visits (0.13) among selected states. Based on the composite score for maternal health utilisation, Kerala, Tamil Nadu, Andhra Pradesh, Odisha, and Delhi were amongst the best performers, whereas Bihar, Jharkhand, Uttar Pradesh, and Assam were amongst the worst performers. This indicates that the government's single-minded focus on enhancing institutional deliveries and skilled health-assisted deliveries has detracted from other essential interventions related to maternal health. Therefore, the states with the utilisation of maternal services need to initiate immediate action to increase the ANC and Post-natal Care (PNC utilisation with more attention towards better implementation of existing ANC programmes by the government.

Women's utilisation of quality antenatal care, intrapartum care and postnatal care services in Ethiopia: a population-based study using the demographic and health survey data

ObjectiveThis study sought to investigate the level and determinants of receiving quality antenatal care (ANC), intrapartum care, and postnatal care (PNC) services by women in Ethiopia. The quality of care a woman receives during ANC, intrapartum care, and PNC services affects the health of the woman and her child and her likelihood of seeking care in the future.MethodsData from the nationally representative Ethiopia Mini Demographic and Health Survey 2019 were analysed for 5,527 mothers who gave birth within five years preceding the survey. We defined quality ANC as having: blood pressure measurement, urine and blood tests, informed of danger signs, iron supplementation, and nutritional counselling during ANC services; quality intrapartum care as having: a health facility birth, skilled birth assistance, and a newborn put to the breast within one hour of birth during intrapartum care services; and quality PNC as having: PNC within two days; cord examination; temperature measurement, and counselling on danger signs and breastfeeding of the newborn; and healthcare provider's observation of breastfeeding during PNC services. We used multilevel mixed-effects logistic regression analyses specifying three-level models: a woman/household, a cluster, and an administrative region to determine predictors of each care quality. The analyses employed sampling weights and were adjusted for sampling design.ResultsThirty-six percent (n = 1,048), 43% (n = 1,485), and 21% (n = 374) women received quality ANC, intrapartum care and PNC services, respectively. Private healthcare facilities provided higher-quality ANC and PNC but poor-quality intrapartum care, compared to public health facilities. Having four or more ANC visits, commencing ANC during the first trimester, and higher women's education levels and household wealth indices were positive predictors of quality ANC use. Government health posts were less likely to provide quality ANC. Wealthier, urban-residing women with education and four or more ANC contacts were more likely to receive quality intrapartum care. Women who received quality ANC and skilled birth assistance were more likely to receive quality PNC. Teenage mothers were more likely to receive quality intrapartum care, but were less likely to receive quality PNC than mothers aged 20–49.ConclusionsWe recommend standardizing the contents of ANC provided in all healthcare facilities; and promoting early and four or more ANC contacts, effectiveness, sensitivity and vigilance of care provided to teenage mothers, and women's education and economic empowerment.

Trend analysis of multi-level determinants of maternal and newborn postnatal care utilization in Pakistan from 2006 to 2018: Evidence from Pakistan Demographic and Health Surveys

BackgroundPostnatal care (PNC) is crucial for maternal and newborn health. Healthcare-seeking practices within the postpartum period help healthcare providers in early detection of complications related to childbirth and post-delivery period. This study aims to investigate trends of PNC utilization from 2006 to 2018, and to explore the effects of multi-level determinants of both maternal and newborn PNC in Pakistan.MethodsSecondary data analysis of the last three waves of the nationally representative Pakistan Demographic and Health Surveys (PDHSs) was conducted Analysis was limited to all those women who had delivered a child during the last 5 years preceding each wave of PDHS Bivariate and multivariate logistic regression was applied to determine the association of maternal and newborn PNC utilization with multi-level determinants at individual, community, and institutional levels.ResultsIn Pakistan, an upward linear trend in maternal PNC utilization was found, with an increase from 43.5 to 63.6% from 2006 to 2018. However, a non-linear trend was observed in newborn PNC utilization, with an upsurge from 20.6 to 50.5% from 2006 to 2013, nonetheless a decrease of 30.7% in 2018. Furthermore, the results highlighted that the likelihood of maternal and newborn PNC utilization was higher amongst older age women, who completed some years of schooling, were employed, had decision-making and emotional autonomy, had caesarean sections, and delivered at health facilities by skilled birth attendants. Multivariate analysis also revealed higher odds for women of older age, who had decision-making and emotional autonomy, and had caesarean section deliveries over the period of 2006–2018 for both maternal and newborn PNC utilization. Further, higher odds for maternal PNC utilization were found with parity and size of newborn, while less for ANC attendance and available means of transportation. Furthermore, increased odds were recorded for newborn PNC utilization with the number of children, ANC attendance, gender of child and mass media exposure from 2006 to 18.ConclusionA difference in maternal and newborn PNC utilization was found in Pakistan, attributed to multiple individual (socio-demographic and obstetrics), community, and institutional level determinants. Overall, findings suggest the need to promote the benefits of PNC for early diagnosis of postpartum complications and to plan effective public health interventions to enhance women’s access to healthcare facilities and skilled birth assistance to save mothers’ and newborns’ lives.

Assessing the relationship between operationally defined zero-dose communities and access to selected primary healthcare services for children and pregnant women in emergency settings.

In this study the authors examine the relationship between "zero-dose" communities and access to healthcare services. This was done by first ensuring the first dose of the Diphtheria Tetanus and Pertussis vaccine was a better measure of zero-dose communities than the measles-containing vaccine. Once ensured, it was used to examine the association with access to primary healthcare services for children and pregnant women in the Democratic Republic of Congo, Afghanistan, and Bangladesh. These services were divided into: a) unscheduled healthcare services such as birth assistance as well as seeking care and treatment for diarrheal diseases and cough/fever episodes and b) other scheduled health services such as antenatal care visits and vitamin A supplementation. Using recent Demographic Health Survey data (2014: Democratic Republic of Congo, 2015: Afghanistan, 2018: Bangladesh), data was analyzed via Chi Squared analysis or Fischer's Exact Test. If significant, a linear regression analysis was performed to examine if the association was linear. While the linear relationship observed between children who had received the first dose of the Diphtheria Tetanus and Pertussis vaccine (the reverse to zero-dose communities) and coverage of other vaccines was expected, the results of the regression analysis depicted an unexpected split in behavior. For scheduled and birth assistance health services, a linear relationship was generally observed. For unscheduled services associated with illness treatments, this was not the case. While it does not appear that the first dose of the Diphtheria Tetanus and Pertussis vaccine can be used to predict (at least in a linear manner) access to some primary (particularly illness treatment) healthcare services in emergency/ humanitarian settings, it can serve as an indirect measure of health services not associated with the treatment of childhood infections such as antenatal care, skilled birth assistance, and to a lesser degree even vitamin A supplementation.

Prevalence of essential newborn care in home and facility births in the Peruvian Amazon: analysis of census data from programme evaluation in three remote districts of the Loreto region

Essential newborn care (ENC) covers optimal breastfeeding, thermal care, and hygienic cord care. These practices are fundamental to save newborn lives. Despite neonatal mortality remaining high in some parts of Peru, no comprehensive data on ENC is available. We sought to estimate the prevalence of ENC and assess differences between facility and home births in the remote Peruvian Amazon. We used baseline data from a household census of rural communities of three districts in Loreto region, collected as part of the evaluation of a maternal-neonatal health (MNH) programme. Women between 15 and 49 years with a live birth in the last 12 months were invited to complete a questionnaire about MNH-related care and ENC. Prevalence of ENC was calculated for all births and disaggregated by place of birth. Adjusted prevalence differences (PD) were post-estimated from logistic regression models on the effect of place of birth on ENC. All 79 rural communities with a population of 14,474 were censused. Among 324 (>99%) women interviewed, 70% gave birth at home, most (93%) without skilled birth assistance. Among all births, prevalence was lowest for immediate skin-to-skin contact (24%), colostrum feeding (47%), and early breastfeeding (64%). ENC was consistently lower in home compared to facility births. After adjusting for confounders, largest PD were found for immediate skin-to-skin contact (50% [95% CI: 38-62]), colostrum feeding (26% [16-36]), and clean cord care (23% [14-32]). ENC prevalence in facilities ranged between 58 and 93%; delayed bathing was lower compared to home births (-19% [-31 to-7]). Low prevalence of ENC practices among home births in a setting with high neonatal mortality and difficult access to quality care in facilities suggests potential for a community-based intervention to promote ENC practices at home, along with promotion of healthcare seeking and simultaneous strengthening of routine facility care. Grand Challenges Canada and Peruvian National Council of Science, Technology, and Technology Innovation.

Women's traditional birth attendant utilization at birth and its associated factors in Angolella Tara, Ethiopia.

In developing countries, home delivery without a skilled birth attendant is a common practice. It has been evidenced that unattended birth is linked with serious life-threatening complications for both the women and the newborn. Institutional delivery with a skilled birth assistance could reduce 20-30% of neonatal mortality. This study aimed to assess traditional birth attendants' (TBAs) utilization and associated factors for women who gave birth in the last two years in Angolella Tara District, Ethiopia. A community-based cross-sectional study was employed among 416 women who gave birth in the last two years at rural Angolella Tara District. Study participants were recruited by using a simple random sampling technique. Data were collected using a structured, pretested, and interviewer-administered questionnaire. Epi Data 4.6 and SPSS version 25 were used for data entry and analysis, respectively. A multivariable logistic regression model was fitted to identify factors associated with women's utilization of traditional birth attendants. The level of significance in the last model was determined at a p-value of &lt;0.05. Overall, 131 (31.5%) participants were used traditional birth attendants in their recent birth. Unmarried marital status (AOR 2.63; 95% CI: 1.16, 5.97), age at first marriage (AOR 2.31; 95%CI: 1.30, 4.09), time to reach health facility (AOR = 3.46; 95% CI: 1.94, 6.17), know danger sign of pregnancy and childbirth (AOR = 5.59, 95% CI; 2.89, 10.81), positive attitude towards traditional birth attendants (AOR = 2.56 95% CI; 1.21,5.52), had antenatal care follow-up (AOR: 0.11 95% CI 0.058, 0.21), and listening radio (AOR = 0.43; 95% CI: 0.18, 0.99) were significantly associated factors with the use of traditional birth attendants. Nearly one-third of women used traditional birth attendant services for their recent birth. TBAs availability and accessibility in the community, and respect for culture and tradition, problems regarding infrastructure, delay or unavailability of ambulance upon call, and some participants knowing only TBAs for birth assistance were reasons for preference of TBAs. Therefore, effort should be made by care providers and policymakers to ensure that modern health care services are accessible for women in a friendly and culturally sensitive manner. In addition, advocacy through mass media about the importance of maternal health service utilization, particularly antenatal care would be important.

Individual and ecological analyses of antenatal care: Prospects for delivery assistance and use of modern family planning in Nigeria.

Despite the availability of healthcare centres for the provision of antenatal care (ANC) services in Nigeria, the services are still underutilized by pregnant women. ANC services not only reduce maternal mortality and birth defects, but also have a strong link to many causes of maternal deaths. This study explored the individual and ecological relationships between antenatal care, skilled birth assistance during delivery, and family planning use across states in Nigeria. This study was a secondary analysis of data from the 2018 National Nutrition and Health Survey (NNHS) carried out among 24,985 women aged 15-49 years in the 36 states and the Federal Capital Territory (FCT) in Nigeria. Analysis was carried out at the level of individual women and at the ecological level. Only 68.3% visited a health professional (doctors, nurses, midwives, community health extension workers, and community health officers) for ANC in the most recent pregnancy before the survey. At delivery, 44.9% were assisted by delivery attendants with about half (50.1%) assisted by non-professional (traditional birth attendants, relatives and friends) during delivery. There was a significant variation in use of modern family planning (FP) across types of ANC provider. There was a strong positive correlation between ANC utilisation and skilled birth attendance (SBA) (r=0.706, p <0.001), and between SBA and FP (r=0.730, p <0.001). These results have implications for the design of appropriate interventions for strengthening the role of healthcare providers to enhance ANC patronage, utilization of safe delivery services and sustained use of reproductive health services.

Child marriage and its association with Maternal Health Care Services utilisation among women aged 20–29: a multi-country study in the South Asia region

Despite pervasiveness of child marriage in South Asian countries, its association with the usage of Maternal Health Care Services (MHCS) is poorly explored. In this study, we examined the impact of child marriage on MHCS utilisation among the prime reproductive aged women of five South Asian countries Afghanistan, Bangladesh, India, Nepal and Pakistan. Data for this study are extracted from the most recent Demographic and Health Surveys. The effect of child marriage on the use of MHCS was assessed by the multivariate logistic regression analysis. Findings reveal that in the South Asian region, the prevalence of child marriage is more common in Bangladesh, followed by Afghanistan, Nepal, India and Pakistan. Child marriage significantly (p< .01) deters the usage of MHCS – at least once antenatal care (ANC) visit, at least four ANC visit, Institutional delivery and seeking assistance from skilled birth assistance (SBA), though the effect size was somewhat different across the countries. Findings stipulate to remain girls in schooling more and the marriage acts of the countries should be enacted properly to diminish child marriage not only for increasing MHCS use, also for individual wellbeing and overall development of each country. Impact Statement What is already known on this subject? Child marriage in South Asian countries is commonplace despite substantial improvements of socioeconomic status. Although child marriage have many adverse reproductive and health outcomes, empirical evidence and systematic studies, particularly the association of child marriage with the usage of Maternal Health Care Services (MHCS) in the South Asian women are few. What do the results of this study add? Findings of this study affirm that prevalence of child marriage in South Asian region is still common. Although every country has set out minimum age at first marriage by acts, the acts are poorly followed, which adversely impacts the usage of MHCS among married women. What are the implications of these findings for clinical practice and/or future research? The study findings provide important insights of the consequence of child marriage on the skilled MHCS utilisation. The marriage acts of the countries should be enacted properly to restrict child marriage not only for increasing MHCS, also for individual wellbeing and overall development of each country. Study has important implications for planners, organisation managers and policy makers.

Trends, regional inequalities and determinants in the utilization of prenatal care and skilled birth attendant in Ethiopia: A multilevel analysis

BackgroundEthiopia has made a substantial reduction in maternal mortality over the last two decades. However, maternal health care utilization among 15–49 aged women remains low despite this progress. The study aimed to examine trends, regional inequalities, and potential determinants associated with prenatal care utilization and a skilled birth attendant from 2000 to 2016 in Ethiopia. MethodsNationally representative data extracted from the 2000 to 2016 Ethiopia Demographic and Health Surveys (EDHS), conducted every five years among 15–49 age women in Ethiopia. We used multilevel logistic analysis incorporating the demographic, socioeconomic, and health variables that are independently associated with prenatal care (PNC) and skilled birth attendant (SBA) use. ResultsThe prevalence of prenatal care utilization was relatively stagnant between 2000 and 2011 but showed an overall increase nationwide from 26.7% to 62.4% between 2000 and 2016 (p-value < 0.001). The prevalence of skilled birth assistance increased only by 16.5% in the past fifteen years, from 5.6% in 2000 to 22.1% in 2016. Rural type of residence, lower maternal education, lower household wealth index, lower partner's education, an immense distance of getting medical help were steadily significantly associated with prenatal health care use and skilled birth attendants. Further, male household heads, younger age women, and no covered health insurance were associated with lower odds of skilled birth attendant use. ConclusionsThough overall prenatal care and skilled birth attendant use prevalence have improved nationally, the regional disparity is uneven. Therefore, to sustain the progress equals more attention is needed for Afar, Somali, and Oromia regions to increase maternal health care services utilization in Ethiopia.

Primary healthcare and child and maternal health in the Middle East and North Africa (MENA): A retrospective analysis of 29 national survey data from 13 countries.

The objective of this paper is three-fold: (i) to analyse the coverage and equity of access to selected maternal and child healthcare interventions, particularly those delivered in Primary Healthcare (PHC) setting; (ii) to analyse the main drivers of inequitable access to selected interventions; and (iii) to synthesise and compare the results across the Middle East and North Africa (MENA) region as well as over time. We analysed data for five key maternal and child healthcare interventions from 29 national surveys (DHS and MICS) covering 13 MENA countries and spanning a period of almost 20 years (2000–2018). We calculated coverage indicators, concentration indices (CI) and decomposition of CIs according to standard definitions. We synthetized the results by country groups based on their human development index (HDI). Over time and among countries that started from a lower base, there has been an improvement in coverage and equity of selected interventions (four ante-natal care visits and skilled birth assistance). When considering the place of skilled delivery, there is a clear rich-poor divide, with women from richer wealth quintiles gravitating toward private healthcare facilities and those from poorer wealth quintiles toward public ones. While most of the care-seeking for common child illnesses occurs in PHC facilities, a fraction (20–30 percent) of care-seeking takes place in secondary healthcare facilities. PHC has played a role in improving coverage and equity of access in key maternal and child health interventions in the wider MENA region. Better integration of care, strengthening and improving the PHC network could increase the use of cost-effective interventions, which are key to improving maternal and child health.

Multidimensional Socioeconomic Deprivations of Maternal Health Care Services Utilisation: Evidence from Bangladesh

This paper examines the combined effect of three socioeconomic deprivations: education, wealth, and health on the utilisation of maternal health care services (MHCSs) among Bangladeshi women using the data of Bangladesh Demographic and Health Survey 2014. Both bivariate and multivariate statistical analyses were employed in this study. Multivariable logistic regression analysis is used to examine the effect of the multidimensional socioeconomic deprivations on the use of MHCSs. Of the women who had given at least one live birth in the three years preceding the survey, 43% were non-deprived by any dimension; 31% were deprived in one, 20% in two and 6% in all three dimensions. The prevalence of receiving four or more antenatal care (ANC) services was 31%; 38% used facility-based delivery (FBD) and 42% sought skilled birth assistance (SBA). When education and wealth deprivations were combined, women were significantly (P&lt;0.01) least likely to seek assistance from SBA (OR=0.18, 95% CI: 0.14-0.24) and FBD (OR=0.17, 95% CI: 0.12-0.22); and when all three deprivations were combined women were less likely to receive ANC at least once (OR=0.16, 95% CI: 0.12-0.22) than those who were not deprived. Programmes should be undertaken to expand maternal health voucher schemes in more sub-districts and quality of care should be ensured for equal accessibility and availability of MHCSs targeting deprived and disadvantaged areas and women to ensure safe motherhood practices in Bangladesh. Our findings show that the situation of maternal health care in Bangladesh is not satisfactory.Antenatal care

Prevalence and Factors Associated with Home Childbirth with Unskilled Birth Assistance in Dodoma-Tanzania: A Cross Sectional Study.

Background:Improving maternal health is one of the goals to be achieved under the Sustainable Development Goal (SDG) number 3. Worldwide, half a million of women die each year from pregnancy and childbirth related complications which can be prevented by skilled birth assistance. One of the determinants of maternal health is place of childbirth. Giving birth at home leads to a high risk of maternal and child mortality. The aim of the study was to determine the prevalence and factors associated with choice of home childbirth in Dodoma Municipality.Methods:A community based cross section study using multistage sampling was used to obtain the sample in which 2,523 women who gave birth within 3 years prior to the date of the study from different wards of Dodoma municipal were interviewed. The data obtained were entered and analysed using SPSS version 20. Binary logistic regression analysis was used to establish predictors of home childbirth with unskilled birth assistance.Results:A total of 1,174 (46.5%) women had home childbirth with unskilled birth assistance. After adjusted for the confounders, predictors of home childbirth with unskilled birth assistance among study respondents were level of education [primary education, AOR=0.69 at 95% CI=0.557-0.854, p<.001; secondary education, AOR=0.492 at 95% CI=0.358-0.676, p<.001 and above secondary education, AOR=0.35 at 95% CI=0.16-0.765;p<.01]; marital status [married women, AOR=0.686 at 95% CI=0.547-0.86, p<.001]; occupation of a mother [peasant, AOR=1.508 at 95% CI=1.214-1.874, p<.05]; parity [2 to 4 children, AOR=1.316 at 95% CI=1.028-1.684, p<.05; More than 4 children, AOR=2.006 at 95% CI=1.427-2.82, p<.001]; number of antenatal visits [4 or more antenatal visits, AOR=0.451 at 95% CI=0.204-0.997, p<.05] and walking distance [less than 5kilometres, AOR= 0.797 at 95% CI=0.674-0.943, p<.001]Conclusion:The findings of this study suggest a need for health education in the community on the importance of skilled birth delivery. There is also a need for the government to roll out the implementation of Primary Health Services Development Program (PHSDP-MMAM) which addresses the delivery of health services within 5 kilometres to ensure fair, equitable and quality health services to the community.

Global Inequality in Maternal Health Care Service Utilization: Implications for Sustainable Development Goals.

Purpose: Globally, low-middle-income countries continue to account for almost all of the pregnancy-related mortalities that are largely preventable through adequate utilization of essential maternal health care services such as antenatal care (ANC) and skilled birth assistance (SBA). Promoting the use of ANC and SBA services are hindered by numerous policy- and capacity-related barriers along with widespread inequality in utilization of the existing services that further exacerbates the scenario. In an attempt to better understand the geography of inequality in service utilization, we conducted this brief descriptive study by using World Health Organization (WHO) data on ANC and SBA utilization among the member states.Methods: This was a descriptive study based on open access data on ANC and SBA use between 2012 and 2015 available through the Global Health Observatory of WHO. Country-level data were collected for Asia (41 countries), Africa (35 countries), Europe (35 countries), North America (10 countries), Latin America and the Caribbean (25 countries), and Oceania (16 countries). Cross-country and continent comparisons were made using dot and bar charts.Results: The overall prevalence of ANC and SBA use were, respectively, 78.17% and 88.33%. Considerable disparities were found in terms of ANC and SBA use across the continents, especially in Asia and Africa. Globally, the poorest performing countries included Afghanistan, Somalia, and South Sudan where more than three-quarters of the women remain deprived of ANC and SBA services during the period of 2012 and 2015. The greatest inequality in ANC use was observed in Africa (9.4% in Somalia and 99.9% in Libya), whereas that of SBA use was observed in Asia (17.8% in Afghanistan vs. 100% in Bahrain). Europe was the most equal of all regions in terms of both ANC (66.8% in Albania vs. 99.7% in Belarus) and SBA (94.4% in Denmark vs. 100% in Lithuania) use.Conclusion: Although in the majority of countries more than three-quarters of the women receive ANC and SBA services, the extent of intraregional inequality remains overwhelming especially for Asia and Africa. Progress toward maternal health-related targets should be interpreted in terms of the disparities to ensure a more even and sustainable outcome at both national and global level.

A first step to improving maternal mortality in a low-literacy setting; the successful use of singing to improve knowledge regarding antenatal care

Preventable maternal mortality is related to delays in recognizing the problem, transport to a facility, and receiving appropriate care on arrival. Reducing maternal mortality in low-literacy settings is particularly challenging. In the rural villages of Nepal, the maternal mortality rate is among the highest in the world; the reasons include illiteracy and lack of knowledge of the needs of pregnant women. Culturally, singing and dancing are part of Nepalese daily life and present an opportunity to transmit knowledge of antenatal care and care at birth with a view to reducing the first 2 delays. We hypothesized that health messages regarding the importance of antenatal care and skilled birth assistance would be effectively transmitted by songs in the limited literacy environment of rural Nepal. We randomly grouped 4 rural village development committees comprising 36 villages into 2 (intervention and control) clusters. In the intervention group, local groups were invited to write song lyrics incorporating key health messages regarding antenatal care to accompany popular melodies. The groups presented their songs and dances in a festival organized and judged by the community. The winning songs were performed by the local people in a song and dance progression through the villages, houses, and fields. A wall chart with the key health messages was also provided to each household. Knowledge of household decision makers (senior men and women) was assessed before and after the intervention and at 12 months using a structured questionnaire in all households that also assessed behavior change. Structured interviews were conducted at baseline, immediately postintervention in the control and intervention areas (intervention n= 735 interviews, control n= 775), and at 12 months in the intervention area only (n= 867). Knowledge scores were recorded as the number of correct items out of 36 questions at baseline and postintervention, and of 21 questions at follow-up. Postintervention, test score doubled in the intervention group from a mean of 11.60/36-22.33/36 (P < .001), with no practically significant change in the control population (17.48/36-18.26/36). Improvement was greatest among the most illiterate members of the community (6.8/36-19.8/36, P < .001). At 12 months follow-up, a majority of the participants (63.9%) indicated that they provided information learned from the songs to their neighbors and friends, and 41.3% reported still singing the songs from the intervention. The use of songs bypassed the limitations of literacy in communicating health messages that are key to improving maternal care in this low-literacy rural setting within a developing country. The improvements were maintained without further intervention for 12 months. With appropriate sociocultural adaptation to local contexts, this low-cost method of community education may be applicable to improving maternal health knowledge and behavior change in other low-resource and limited literacy settings that may lead to reductions in maternal mortality.

The impacts of migration on maternal and child health services utilisation in Sub-Saharan Africa: evidence from Togo.

Togo is experiencing a growing phenomenon of migration and consequently receives remittances from international migrants back to their relatives. Remittances represent about 9.4% of the gross domestic product (GDP), placing Togo in the top 10 recipients of remittances in the world in 2014. Despite the importance of remittances, information on their health outcomes is inadequate, particularly if remittances have a positive impact on the utilisation of maternal and child health services. The aim of this article is to evaluate the impacts of migration on maternal and child health services utilisation. Cross-sectional data analysis of mothers aged 15-49 years who have recently given birth. We used propensity score matching to compare the utilisation of health services by mothers and children from households with migrants to those without migrants. We simulated a potential confounder to assess the robustness of the effects of the estimated treatment (i.e. migration). We also addressed the problem of hidden biases with the bounding approach. Deliveries attended by skilled health personnel were found to be 10.3% higher in migrant households than in households without migrants. The antenatal visits of mothers in migrant households were 3.5%-9.5% higher than those of matched control groups. Compared to the non-migrant households, the migrant households had a positive welfare (postnatal checks at the hospital) impact of 11.9%-12.5% percentage points. Furthermore, through access to health insurance, mothers in migrant families enjoy more financial protection with regard to delivery, prenatal and postnatal care. We also found that children in migrant households benefit from more preventive health inputs such as postnatal checks and vaccinations. Our results suggest that migration contributes greatly to improving births at hospitals, skilled birth assistance, and utilisation of antenatal and postnatal care through the return flow of financial resources. Efforts in health care reforms in Togo should take into account the scope of the positive impacts of migration on the utilisation of maternal and child health services.

Association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia

BackgroundThe postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia.MethodsData for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use.ResultsBetween rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 – unlike those in 2011 – with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care.ConclusionsA comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals.

Equity of access to maternal health interventions in Brazil and Colombia: a retrospective study

BackgroundReducing maternal mortality is a top priority in Latin American countries. Despite the progress in maternal mortality reduction, Brazil and Colombia still lag behind countries at similar levels of development.MethodsUsing data from the Demographic Health Survey, this study quantified and compared, by means of concentration indices, the socioeconomic-related inequity in access to four key maternal health interventions in Brazil and Colombia. Decomposition analysis of the concentration index was used for two indicators – skilled attendance at birth and postnatal care in Brazil.ResultsCoverage levels of the four key maternal health interventions were similar in the two countries. More specifically, we found that coverage of some of the interventions (e.g. ante-natal care and skilled birth assistance) was higher than 90% in both countries. Nevertheless, the concentration index analysis pointed to significant pro-rich inequities in access in all four key interventions in both countries. Interestingly, the analysis showed that Colombia fared slightly better than Brazil in terms of equity in access of the interventions studied. Finally, the decomposition analysis for the presence of a skilled attendant at birth and postnatal care in Brazil underlined the significance of regional disparities, wealth inequalities, inequalities in access to private hospitals, and inequalities in access to private health insurance.ConclusionsThere are persistent pro-rich inequities in access to four maternal health interventions in both Brazil and Colombia. The decomposition analysis conducted on Brazilian data suggests the existence of disparities in system capacity and quality of care between the private and the public health services, resulting in inequities of access to maternal health services.