Maternal Care Utilization Research Articles

Antenatal physical activity: Investigating the effects on postpartum depression

Engaging in regular moderate-intensity physical activity has been demonstrated as a successful treatment modality for both major and minor depression and as effective as pharmacologic treatments. However, less is known about the use of antenatal physical activity as a preventive modality for depression during the perinatal period. The objective of the present study was to determine if there is an association between antenatal physical activity and PPD. A cross-sectional study using the 2007-2008 Pregnancy Risk Assessment Monitoring System (PRAMS) data from Colorado and North Carolina (N = 6026) was conducted. PRAMS self-reported data are from a large randomized sample collected by the CDC that assesses maternal demographic, socio-economic, and prepregnancy and perinatal behaviors. Multivariable logistic regression was used to examine the relationship between antenatal sedentary behavior and PPD. Upon adjusting for maternal age, education, race, marital status, parity, stress, smoking, drinking, and prenatal care utilization, women who did not engage in antenatal physical activity were 1.34 times more likely to screen positive for PPD than women who exercised 5 or more days per week [OR 1.34; 95% CI: (1.04, 1.74); p = 0.03]. These findings suggest that not engaging in antenatal exercise may be associated with an increase risk of PPD. Further research is warranted to better understand the effects of antenatal sedentary behavior on PPD and the potential use of physical activity as a preventive modality for PPD.

Investigation of maternal care utilization rate for women in minority areas

Objective To probe into the maternal care utilization by minority women, for the purpose of policy recommendations on better maternal care in minority areas. Methods A combination of stratified random sampling and typical sampling was made on 445 married women of reproductive age in six counties in Yunnan, Guizhou, Qinghai and Tibet provinces, a field survey on their utilization of maternal care services. Results Their average prenatal detection rate is 78.24％, a level lower than the national rural average of 93.7％ and grade-4 rural average of 81.2％ in 2008; their post partook rate is 30.7％, lower than the national rural average of 54.3％ and grade-4 rural average of 58.9％ in the same period; their average coverage rate is 52.18％, a level lower than the national rural average of 87.1％and grade-4 rural average of 64.3％ in 2008. Conclusion The maternal care utilization is found to be low for women in minority areas. Effective solutions are expected for payment of indirect expenditure of hospital delivery; better health education for enhancing health knowledge and health awareness of minority women; effective incentive mechanism for village doctors, consolidating the base of the three-level healthcare network. Key words: Minority areas; Pregnancy; Healthcare; Utilization

Evaluation of a community-based randomized controlled prenatal care trial in rural China

BackgroundA community-based randomized control prenatal care trial was performed in a rural county of China during 2000-2003. The purpose of this paper is to describe the trial implementation and the impact of the trial on the utilization of prenatal care and perinatal outcomes.Materials and methodsIn the study county, 10 townships (from a total of 55) were each paired with a control (20 study townships in total), with the criteria for pairing being the township's socioeconomic development, perinatal health, and maternal care utilization and provision. One of each township pair was randomly allocated to the intervention or control groups. The trial interventions were: 1) training township hospital midwives and instructing them in how to provide systematic maternal care, 2) informing women in the community of the importance of prenatal care, 3) if needed, providing basic medical instruments to the hospitals. A variety of data sources were used to describe the trial implementation (observations, group discussions, field notes, survey to women). The data on pregnancy and perinatal outcomes were from the original hand-written work-records in the village family planning centers of the study townships.ResultsImplementation of the intervention was deficient. The factors hindering the trial implementation included poor coordination between midwives and family planning officers, broader policy changes implemented by the provincial government during the trial, the decentralization of county governance, and the lack of government funding for maternal care. There was only little difference in the use of maternal care, in women's opinions related to maternal care or content of prenatal care, and no difference in the perinatal outcomes between the intervention and control townships.ConclusionsA community based randomized controlled trial could not be fully carried out in rural China as planned due to the changing political landscape, the complexity of the socio-economic situation and a lengthy planning stage. The study could not answer if perinatal outcomes could be improved by increased use of prenatal care.Trial registrationNCT 01054235

Changes and Equity in Use of Maternal Health Care in China: from 1991 to 2003

To examine changes and equity in use of maternal care in different types of rural and urban areas in China from the early 1990s to early 2000s. Data were drawn from three National Health Household Interview Surveys conducted in 1993, 1998, and 2003. Analysis was based on married women aged between 15 and 49 who had live births within the 24 months prior to the survey. Nationally, the proportion of women receiving their first pre-natal visit within 12 weeks of gestation and the hospital delivery rate increased rapidly from 20.56 and 37.61% in the early 1990s to 52.60 and 74.02% in the early 2000s, respectively, while the proportion of women receiving at least one post-natal care visit dropped slightly from 56.46 to 54.12% in the same time period. There were large disparities in use of maternal care between urban and rural areas and among different sized cities and rural areas with different levels of socio-economic development. But the disparities narrowed over time, especially among different types of rural areas. The proportion of delivery out of hospital attended by trained staff in rural areas decreased considerably from 68.01% in 1991-1993 to 51.57% in 2001-2003. Maternal care utilization made remarkable progress in the study period, and the gap between rural and urban areas and among different classes of cities and rural areas significantly narrowed. This was probably due to both socio-economic development and targeted investments in improving health services. However, significant gaps remained, requiring attention.

Using Vouchers to Increase Access to Maternal Healthcare in Bangladesh

The maternal mortality ratio (322) is comparatively high in Bangladesh. The utilization of maternity care provided by trained professionals during and after delivery is alarmingly low, primarily due to lack of knowledge and money. The overall objective of this operations research project was to test the feasibility and effectiveness of introducing financial support (voucher scheme) for poor rural women to improve utilization of antenatal care (ANC), delivery and postnatal check-up (PNC) from trained service providers. A pretest-posttest design was utilized. A total of 436 women were interviewed before and 414 after the intervention to evaluate the impact of interventions. In-depth interviews were conducted with users and non-users of vouchers. Findings show that institutional deliveries have increased from 2% to 18%. Utilization of ANC from trained providers has increased from 42% to 89%. Similarly, utilization of PNC from trained providers has increased from 10% to 60%.

Healthy mothers, healthy children: does maternal demand for antenatal care matter for child health in Nepal?

Nepal's Safe Motherhood Programme has failed to deliver expected gains in maternal and child health. Nepalese mothers and their children continue to dispense with (or be denied) antenatal care, experience high maternal mortality rates and suffer chronic malnutrition. We address the correlates and consequences of antenatal care utilization in Nepal by applying two-stage least squares, binomial logit and Heckman selection bias estimates to data drawn from the Nepal Health and Demographic Surveys of 1996 and 2001. Results indicate that maternal education, even at low levels, significantly increases the use of antenatal care; paternal education plays a more important role in the use of routine antenatal care than the conventional wisdom suggests; and when mothers use routine professional antenatal care and maintain good health their children tend to stay healthy through infancy and early childhood. Since health-seeking behaviour is circumscribed by patriarchal gender norms in Nepal, health policies should not only focus on female education and women's status, but also involve husbands in the process of maternal care utilization.

The evaluation of "Safe Motherhood" program on maternal care utilization in rural western China: a difference in difference approach

BackgroundMaternal care is an important strategy for protection and promotion of maternal and children's health by reducing maternal mortality and improving the quality of birth. However, the status of maternal care is quite weak in the less developed rural areas in western China. It is found that the maternal mortality rates in some western areas of China were 5.8 times higher than those of their eastern costal counterparts. In order to reduce the maternal mortality rates and to improve maternal care in western rural areas of China, the Chinese Ministry of Health (MOH) and the United Nations Children's Fund (UNICEF) sponsored a program named "Safe Motherhood" in ten western provinces of China from 2001 through 2005. This study mainly aims to evaluate the effects of "Safe Motherhood" program on maternal care utilization.Methods32 counties were included in both surveys conducted in 2001 and 2005, respectively. Ten counties of which implemented comprehensive community-based intervention were used as intervention groups, while 22 counties were used as control groups. Stratified 3-stage probability-proportion-to-size sampling method was used to select participating women. Two cross-sectional surveys were conducted with questionnaires about the prenatal care utilization in 2001 and 2005, respectively. Difference in difference estimation was used to assess the effect of intervention on the maternal care utilization while controlling for socio-economic characteristics of women.ResultsAfter the intervention, the proportion of pregnant women who had their first prenatal visit in the first trimester was increased from 38.9% to 76.1%. The proportion of prenatal visits increased from 82.6% to 98.3%. The proportion of women mobilized to deliver in hospitals increased from 62.7% to 94.5%. Hospital delivery was improved greatly from 31.1% to 87.3%. The maternal mortality rate was lowered by 34.9% from 91.76 to 59.74 per 100,000 live births. The community-based intervention had increased prenatal visits rate by 5.2%, first prenatal visit in first trimester rate by 12.0% and hospital delivery rate by 22.5%, respectively. No effect was found on rate of women being mobilized to hospital delivery compared with that of the control group.ConclusionThe intervention program seemed to have improved the prenatal care utilization in rural western China.

Maternal mortality estimation at the subnational level: a model-based method with an application to Bangladesh

To provide a model-based method of estimating maternal mortality at the subnational level and illustrate its use in estimating maternal mortality rates (MMrates) and maternal mortality ratios (MMRs) in all 64 districts of Bangladesh. Knowing that mortality is more pronounced among the poorer segments of a population, in rural areas and in areas with poor availability and utilization of maternal care, we used an empirical Bayesian prediction method to estimate maternal mortality at the subnational level from the spatial distribution of such factors. MMRs varied significantly by district in Bangladesh, from 158 maternal deaths per 100,000 live births at Dhaka district to 782 in the northern coastal regions. Maternal mortality was consistently higher in the eastern and northern regions, which are known to be culturally conservative and to have poor transportation systems. Bangladesh has made noteworthy strides in reducing maternal mortality since 1990, even though the utilization of skilled birth attendants has increased very little. However, several areas still show alarmingly high maternal mortality figures and need to be prioritized and targeted by health administrators and policy-makers.

Health system performance at the district level in Indonesia after decentralization

BackgroundAssessments over the last two decades have showed an overall low level of performance of the health system in Indonesia with wide variation between districts. The reasons advanced for these low levels of performance include the low level of public funding for health and the lack of discretion for health system managers at the district level. When, in 2001, Indonesia implemented a radical decentralization and significantly increased the central transfer of funds to district governments it was widely expected that the performance of the health system would improve. This paper assesses the extent to which the performance of the health system has improved since decentralization.MethodsWe measured a set of indicators relevant to assessing changes in performance of the health system between two surveys in three areas: utilization of maternal antenatal and delivery care; immunization coverage; and contraceptive source and use. We also measured respondents' demographic characteristics and their living circumstances. These measurements were made in population-based surveys in 10 districts in 2002-03 and repeated in 2007 in the same 10 districts using the same instruments and sampling methods.ResultsThe dominant providers of maternal and child health in these 10 districts are in the private sector. There was a significant decrease in birth deliveries at home, and a corresponding increase in deliveries in health facilities in 5 of the 10 districts, largely due to increased use of private facilities with little change in the already low use of public facilities. Overall, there was no improvement in vaccination of mothers and their children. Of those using modern contraceptive methods, the majority obtained them from the private sector in all districts.ConclusionsThere has been little improvement in the performance of the health system since decentralization occurred in 2001 even though there have also been significant increases in public funding for health. In fact, the decentralization has been limited in extent and structural problems make management of the system as a whole difficult. At the national level there has been no real attempt to envision the health system that Indonesia will need for the next 20 to 30 years or how the substantial public subsidy to this lightly regulated private system could be used in creative ways to stimulate innovation, mitigate market failures, improve equity and quality, and to enhance the performance of the system as a whole.

Utilization of maternity care in Nigeria

This paper discusses the differentials of maternity care in Nigeria. The objective is to provide information that could form basis for the design, implementation and monitoring of strategies for improved maternity care and hence, of maternal health, in line with the fifth Millennium Development Goal. To achieve this objective, secondary data derived from the 1990, 1999 and 2003 Nigeria Demographic and Health Surveys (NDHS) were analysed using simple descriptive statistics and cross-tabulations. The results of the analyses show that, though the status of maternity care, as measured by Care with a Health Professional (CHP), Delivery with a Health Professional (DHP) and Delivery Within a Health Facility (DHF), in Nigeria is generally low, it is worse in the rural than urban areas. It appears lowest among women under 20 years and lowest in the Northwest region of Nigeria. The level of maternity care also appears to have increased as mother’s education and wealth quintile increased and decreased as birth order increased. Therefore, improved mother’s education and economic status have been recommended among others, as a means of improving the status of maternity care in Nigeria.

Does Elective Caesarean Section Increase Utilization of Postpartum Maternal Medical Care?

There have been no studies that quantitatively assess postpartum maternal medical care utilization for elective caesarean section (CS) versus vaginal delivery procedures. This study used population-based data linked with birth file data to explore the association between delivery modes (elective CS vs. vaginal delivery) and the utilization of postpartum maternal medical care (outpatient visits and inpatient care) during the 6-month postdelivery period. The analysis was restricted to term deliveries to avoid biased estimation. The average number of postpartum outpatient visits for elective CS (3.14) was slightly higher than the average number of visits for vaginal deliveries (2.87). Similarly, the total amount of postpartum maternal medical expenditures involved was slightly higher for elective CS than for vaginal deliveries [NT$2811 (US$73.6) vs. NT$2570 (US$71.4)]. The likelihood of postpartum outpatient visits taking place within the 6-month postdelivery period was also slightly higher for elective CS than for vaginal deliveries (77% vs. 70%). The regression results showed that elective CS was associated with significantly higher utilization of maternal medical care compared with vaginal deliveries. Although the difference between elective CS and vaginal deliveries in terms of postpartum medical care utilization is statistically significant, the small magnitude of the difference in cost (NT$72; US$2.2) suggests that it may not be clinically significant, and may only be marginally important from a policy perspective.

Antenatal and maternal health care utilization: evidence from northeastern states of India

This article examines the role played by the various socio-economic and community level factors in determining the antenatal and maternal health care utilization pattern using the data from the National Family Health Survey carried out in India in 1998/99. Our analysis document that autonomy enjoyed by women and exposure to media has a significant impact on maternal heath care utilization even after controlling for other attributes, particularly their education and household economic status. Availability of a rural health facility in the village and other community level programme propagates the utilization of health care.

Factors influencing non-utilisation of maternity care services in Sagamu, South Western Nigeria

Objective: To determine the factors influencing the utilization of maternity care in the public health facilities in the Sagamu Community. Materials and Methods: With the aid of pre-tested structured interview questionnaires, a comparative cross-sectional study was conducted in Sagamu among expectant mothers patronizing the traditional birth attendants (TBAs) and the public maternity centres, so as to determine the factors responsible for the non-utilization of skilled maternity care and the utilization of health services by the expectant mothers in Sagamu community in September 2002. The process indicator of skilled care at delivery (i.e. percentage of births assisted by skilled attendants) is the United Nations General Assembly recommendation (1999) being used as a benchmark indicator to measure progress towards reducing maternal mortality. Results: Religion, cost of services and distance to the health facilities were found not to be contributory to the non-utilization of health facilities. Rather, socio-cultural beliefs in the TBA services, low educational status, and husband and family decision (gender influence) were found to be strong determinants of the non-utilization of the maternity centres by expectant mothers in this community. Improving the educational status of women, reducing the waiting time at hospitals, improving the quality of care and raising women's status so that they are empowered to make critical health decisions will enhance the use of skilled maternity care and utilization of health facilities by expectant mothers. Conclusion: It is recommended that qualitative research should be conducted in every community to identify traditional beliefs, customs and taboos that may be a deterrent to utilization of skilled maternity care. The information obtained should be used to develop a health communication plan for the community on maternal care. Keywords: maternal mortality, maternity services, traditional birth attendants (TBA) Tropical Journal of Obstetrics and Gynaecology Vol. 23(1) 2006: 48-53

'Breaking it down': patient-clinician communication and prenatal care among African American women of low and higher literacy.

Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored. We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy. Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care. Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.

Do individual and program factors matter in the utilization of maternal care services in rural India? A theoretical approach

Current studies on the utilization of maternal care services in India focus on individual factors. In the present study, we use the theoretical model developed by Andersen and Newman [1973. Societal and individual determinants of medical care utilization in the United States. Milbank Memorial Fund Quarterly, 51(1), 95–124] to understand the utilization of maternal care services in rural areas of India. This theoretical model uses individual and welfare program—or system factors—to study health care utilization. Data collected through the National Family Health Survey-2 are used in the present study. The results suggest that in addition to individual characteristics, program and system factors influence the utilization of maternal care in rural areas. Program factors, particularly educational activities promoting the benefits of maternal care services carried out through mahila mandal and anganwadi centers, are important in increasing the use of maternal care services in rural areas. Additionally, the results indicate that the mere presence of a private health care facility need not necessarily improve utilization. Increase in utilization is observed among households if the health worker visited these households during pregnancy. More state-specific studies incorporating both program and individual characteristics are recommended to further strengthen our understanding of the utilization of health care services in general and maternal care services specifically.

Factors influencing utilisation of adolescent maternal care: An explorative study

Cross sectional data collected from rural and urban areas of Bangladesh to assess the pattern of utilisation of maternal care and the factors influencing it showed that about 58% of the adolescent mothers did not receive any maternal care during pregnancy. In multivariate logistic regression, the level of education of the mothers was significantly associated with antenatal care-seeking, but did not predict utilisation of delivery care. It was complications during delivery that compelled mothers to take care from qualified persons; otherwise they preferred delivery by non-qualified birth attendants. A variety of societal factors such as gender inequality and intra household power imbalance are likely to have been at work, which suggests that care providers and policy makers need to consider not only the resources of the health care system, but also knowledge and attitudes of women, their families, and the community.

Utilization of maternal care in rural HeBei Province, the People’s Republic of China: individual and structural characteristics

Purpose: To study the effect of individual’s socio-economic characteristics and the structure of the health services in the village on utilization of maternal care in rural HeBei, the People’s Republic of China (PRC). Data: Data were collected from 4273 women who gave birth to one child at least, living in a stratified sample of 288 villages in HeBei Province. Findings: 54.8% of the women had at least one pre-natal care visit, 27.5% gave birth in a health care facility, and 18.1% had post-natal check-up. Utilization was inversely related to age and parity and positively to education. Occupation was related to use of pre- and post-natal services, but not to home birth. Per-capita income and living arrangement are not related to utilization. MCH worker in the village promote pre- and post-natal care, but also home delivery. Village doctors promote pre-natal care and hospital delivery but do not promote post-natal check-up. Women tend to avoid the maternal services in the township health centers but some are ready to travel to city hospitals for delivery and post-natal care. Conclusions: Health education programs regarding the importance of all three maternal care services are clearly needed. These programs should address not only women of child bearing age but also care providers, MCH workers in particular. Township health center should reach-out and motivate women to use their accessible services.

Factors Governing Maternal Health Care Utilisation: Evidence from Rural India

This paper examines the role played by the various socio-economic and community level factors to determine the maternal health care utilisation using the data from National Family Health Survey (NFHS) carried out in 1998-99 in India. Our analysis document that autonomy enjoyed by women and exposure to media has a significant impact on maternal heath care utilization even after controlling for other attributes particularly her education and household economic status. Women with delivery complications are found to be aware of the risks involved and keener to seek institutional care. Availability of a government facility has no bearing on the respondent's utilization choice but presence of a private facility in the village propagates the utilization of a private health facility in contrast to delivering at home. The results show that even after controlling for availability of both public as well as private health facility, development of the village infrastructure and other informative community level programmes are required to mitigate the cultural and economic barriers that deter the use of maternal services. Furthermore, the obtained results provide insights for formulating health policies. Policies should be oriented to meet the specific needs of individuals particularly those belonging to the vulnerable social groups. Fortunately, women with delivery complications were found to be aware of the risks involved and more keen to seek institutional care (public or private). This highlights the importance of devising health services and programmes aimed at early detections of obstetric problems.

The influence of proximity of prenatal services on small-for-gestational-age birth.

Some studies suggest that prenatal services may decrease the risk of poor fetal growth for full-term infants, but have not examined the influence of the availability of community health and social services. The availability of prenatal services may have a stronger effect among women already at high risk of a small-for-gestational-age (SGA) birth. Singleton full-term (> or = 37 weeks gestation) California births for 1997-98 (n = 744,736) were geocoded to maternal Census tract of residence. Women were placed into one of three demographic risk groups utilizing combinations of maternal age, marital status, parity, and education. SGA was defined as birthweight less than the 10th percentile for gestational age. Locations of WIC sites, prenatal care providers, and perinatal outreach programs were geocoded. Multilevel logistic regression was used to model the influence of community health care services on SGA, adjusting for additional maternal and community factors. There was no association between SGA and community services available for either high- or low-risk women, in either unadjusted or adjusted models. The addition of maternal prenatal care utilization to models did not change the results. Maternal residence near prenatal services was not associated with SGA, regardless of demographic risk; other community factors may warrant consideration.

Utilization and Provider Choice in Maternal and Child Health Care in Hsintien City: A Review of the Role of the Health Station

A probability proportional to size (PPS) sample of 320 infants was drawn from 1102 infants between 13 and 16 months of age from the city of Hsintien, a satellite city of Taipei. Home visits and questionnaire interviews were conducted for all of the mothers by eight trained interviewers in September, 1990. Utilization and provider choice of maternal and child health care of these infants were investigated. Most of the mothers had had prenatal care and postnatal care and were currently using contraceptive methods, the rates were 99.1%, 78.8%, and 77.0% respectively. Only 31.1% had had Pap smears in the past year. In all, 81.5% of the infants had had neonatal screening, and 77.9% had had well baby examinations. The rate for completion of all immunizations before one year of age exceeded 90%. Almost all maternal care was provided in hospitals or clinics. Health stations were used more often for infant care, and usage increased as the baby grew older. None of the neonatal screening was provided in health stations. About 30% of the immunizations within one month and over 70% of the immunizations after one month were given in health stations. Stepwise multiple regression analysis shows that total use of health stations by completely immunized babies was positively related to the understanding of health stations, accessibility, and the need for cheap or free care, while being negatively related to requirements of good attitude and of attending delivery. The authors suggest a review the role of health stations and thedevelopement of an integrated health care system to organize all possible resources.