Maternal Care Utilization Research Articles

Trends in Maternal Care Utilization in Urban India

The present study attempts to observe the recent changes in the Indian health care utilization pattern based on secondary data from three National Sample Survey Organisation (NSSO) rounds. The study focuses on urban households across different classes of towns emphasizing the most recent births to married women within a recall of period 365 days. Three dimensions of maternal care services have been discussed in this study, namely, prenatal care services, delivery services and postnatal care services. It is found that the utilization of prenatal, postnatal and delivery services are positively correlated with the economic status of households as measured by the per capita monthly consumption expenditure (MPCE). It is also noted that the household educational and employment index are correlated with the level of prenatal and postnatal care utilization and the dimension of correlation is positive and statistically significant. But in case of delivery services the degree of correlation has changed from being highly positive to negative, specifically in case of household employment index. This study also attempts to understand the changes in utilization of maternal health care services with respect to public health infrastructure. It is found that the use of public health facilities has significantly reduced over time. The correlation between household economic status and the use of public facilities for the prenatal, postnatal and delivery care present a strong negative and the degree of correlation becomes stronger over time. A similar dimension of association is found in the case of household educational index. It may be the improvement in utilizing public health infrastructure among households from the formal sector. The discrepancy in access to health facilities among different classes of cities can be cited as one of the reasons for lower utilization of maternal health care services. Such discrepancies are relatively lower in case of small towns especially in the case of delivery and prenatal care services.

Equity in maternal health care service utilization: a systematic review for developing countries.

The objective was to explore progress of equity in the utilization of maternal health care services in developing countries since maternal care is a crucial factor in reducing maternal mortality, which is targeted by the Millennium Development Goal 5. A systematic review of quantitative studies was done. PubMed Central, Web of Science, and Science Direct databases were searched for peer-reviewed and English-language articles published between 2005 and 2015. Thirty-six articles were included in the review. The results reveal the lack of equity in the utilization of maternal health care in developing countries. Thirty-three out of 36 studies found evidence supporting severe inequities while three studies found evidence of equity or at least improvement in terms of equity. Most of the literature devoted to utilization of maternal health care generally provides information on the level of maternal care used and ignore the equity problem. Research in this area should focus not only on the level of maternal care used but also on the most disadvantaged segments of the population in terms of utilization of maternal care in order to reach the set targets.

PHS117 - Reducing maternal and Child Mortality in Ghana: is National Health Insurance scheme’s free maternal care programme helping?

To evaluate the impact of the National Health Insurance Scheme’s Free Maternal Care Program (FMCP) on maternal health care utilization and mortality rates. Review and participant observation methods were employed to review maternal care utilization data from the NHIS and Ghana Health Service over the 2005- 2012 period. Maternal and child mortality data from UN Inter-agency Group for Child Mortality Estimation (WHO, UNICEF, UN DESA, UNPD, World Bank) were also reviewed. The amount of money paid for maternal health services increased from GHS21.9 million (USD6.88m) in July 2008 to GHS52.4 million (USD16.39m) in December, 2009. As of June 2010, an amount of GHS26.3 million (USD8.24m) had been paid. Antennal care coverage (at least four visits) increased from 61% to 72% between 2008 and 2012; postnatal care coverage increased from 54% to 58% between 2006 and 2008 and went up to 65% in 2011; skilled delivery saw no improvement between 2006 and 2008 (44%) but went up to 59% in 2012. The institutional maternal mortality ratio (IMMR) recorded a reduction of 7% over the 2005-2008 period and went down considerably by 23% to 155 deaths per 1000 live births over the post 2008 period. Under-five mortality rate declined from 88.4 to 83 deaths per 1000 live births (5.4%) between 2005 and 2008; it went down to 72 deaths per 1000 live births (11%) over the post 2008 period. There have been substantial improvement in maternal care utilization and reduction in mortality rates five years after full implementation of the FMCP. However, big gaps exist between the current mortality rates and MDG 4 and 5 targets, with barely a year to the 2015 deadline. Therefore, much effort is needed from government, development partners, and maternal care advocates to accelerate progress towards achieving MDG 4 and 5.

Improving support in pregnancy after stillbirth or neonatal death: IMPs study

The death of a baby before or shortly after birth is associated with profound long lasting grief for parents, similar to any child death.[1] The majority of women who suffer a stillbirth will embark on another pregnancy, with around 50% becoming pregnant within a year of the loss.[2] Subsequent pregnancies are characterised by elevated maternal anxiety and emotional vulnerability which often extends beyond the postnatal period, increasing the risk of adverse pregnancy outcomes and disrupted attachment, a potential cause of parenting and social difficulties in the longer term.[2-4] Recent evidence suggests the effects are not limited to mothers and that fathers also experience psychological distress during this period.[5] A recent metasynthesis of the qualitative literature surrounding parents’ experiences of care highlighted the value of additional emotional and psychological support from healthcare providers in improving care in pregnancy after stillbirth or neonatal death.[6] However, there is a dearth of evidence to whether parents’ needs for emotional and psychological support are being met by current maternity services in the UK. This programme of research aimed to explore current UK practice and provision of support in pregnancy for parents following stillbirth or neonatal death. An action research approach was utilised with stakeholder involvement central to the design and conduct of the study.[7] Online surveys, including open and closed questions, provided an overview of current service provision in UK maternity units and women’s experiences. Qualitative phenomenological interviews provided an in-depth exploration of the lived experiences of women and health professionals. Data from 138 maternity units (≈60% total) demonstrated variable provision, emphasis on surveillance and monitoring with less attention to psychological and emotional support. A few units had developed innovative services/programmes targeted at this group, but lack of evaluation and dissemination was a barrier to sharing good practice. Analysis of the responses of 547 women, across all UK regions, demonstrated high levels of engagement and utilisation of maternity care. Many women reported positive experiences and recognised professionals who demonstrated empathy and compassion in providing high-quality care which often exceeded their expectations. However, a significant minority of women recounted poor experiences. Insensitive communication was often related to the attitudes and behaviours of individual professionals; however, organisational factors particularly a lack of continuity of care provider and service fragmentation common in standard UK model of ‘high-risk’ antenatal care were consistently and repeatedly associated with decreased satisfaction with care. Ongoing qualitative work will explore these issues in greater depth. Interim findings of this programme raise the issue of equity in provision of appropriate and sensitive care for parents in subsequent pregnancies who utilise UK maternity services. Data suggests that many parents receive inadequate emotional and psychological support and therefore there is a need to improve the evidence base underpinning care. The findings of this study will directly inform the development of specific interventions to improve antenatal support and promote positive birthing experiences and the development of a clinical care pathway to improve the care of women and their families in pregnancy following perinatal loss.

Impact of the Mandatory Community Midwifery Service on the Utilization of Maternal Health Care by Women in Ondo State, Nigeria

The study explored the perceived impact of the mandatory community midwifery service on utilization of maternal health care by women, using the General System Theory and the Logic Model. The research was conducted in three selected Local Government Areas (LGAs). The research design for this study was the time-series type of non-controlled experimental design. The researcher assessed records of maternal health care attendance from the selected health facilities from July 2002 to July 2011 to generate data for the study. The study population comprised of 306 women of reproductive age group (15-49) in the three selected communities (who have participated in the programme) where the three primary health care centres are located. Multistage sampling technique was adopted to select three Local Government Areas (LGAs) from where data was collected. In-depth interview guide, questionnaire and format for recording data from records were used in the study. The result obtained from the study indicated that there was no significant difference in the levels of utilization of maternal care services before and after the inception of the mandatory community service except for the slight increase in antenatal care utilization. Majority of the women expressed satisfaction with the services they received from the midwives. The study also revealed a slight increase in the levels of utilization of antenatal attendance while not much change had occurred in the use of facility based delivery care as well as postnatal care.

Social inequalities in the utilization of maternal care in Bangladesh: Have they widened or narrowed in recent years?

BackgroundNotwithstanding the significant progress in reducing maternal mortality in recent years, social inequalities in the utilization of maternal care continue to be a challenge in Bangladesh. In this study, we aim to provide a comprehensive analysis of trends in social inequalities in utilization of antenatal care (ANC), facility based delivery (FBD), and skilled birth attendance (SBA) in Bangladesh between 1995 and 2010.MethodsData were extracted from the five latest rounds of Bangladesh Demographic Health Surveys (BDHS). The Theil index (T) and between-group variance (BGV) were used to calculate relative and absolute disparities in the utilization of three measures (ANC, FBD, and SBA) of maternal care across six administrative regions. The relative and slope indices of inequality (RII and SII, respectively) were also used to calculate wealth- and education-based inequality in the utilization of maternal care.ResultsThe results of the T-index suggest that relative inequality in SBA has declined by 0.2% per year. Nevertheless, the estimated BGV demonstrated that absolute inequalities in all three measures of maternal care have increased across administrative divisions. For all three measures of maternal care, the RII and SII indicated consistent socioeconomic inequalities favouring wealthier and more educated women. The adjusted RII suggested that wealth- and education-related inequalities for ANC declined by 9% and 6%, respectively, per year during the study period. The adjusted SII, however, showed that wealth- and education-related inequalities for FBD increased by 0.6% per year.ConclusionsAlthough socially disadvantaged mothers increased their utilization of care relative to mothers of higher socioeconomic status, the absolute gap in utilization of care between socioeconomic groups has increased over time. Our findings indicate that wealthier and more educated women, as well as those living in urban areas, are the major users of ANC, FBD and SBA in Bangladesh. Thus, priority focus should be given to implementing and evaluating interventions that benefit women who are poorer, less educated and live in rural areas.

The effects of performance incentives on the utilization and quality of maternal and child care in Burundi

Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited. In this study we aim to estimate the effects of PBF on the utilization and quality of maternal and child care in Burundi. We use the 2010 Burundi Demographic and Health Survey (August 2010–January 2011, n = 4916 women) and exploit the staggered rollout of PBF between 2006 and 2010, to implement a difference-in-differences approach. The quality of care provided during antenatal care (ANC) visits improved significantly, especially among the better off, although timeliness and number of ANC visits did not change. The probability of an institutional delivery increased significantly with 4 percentage points among the better off but no effects were found among the poor. PBF does significantly increase this probability (with 5 percentage points) for women where PBF was in place from the start of their pregnancy, suggesting that women are encouraged during ANC visits to deliver in the facility. PBF also led to a significant increase of 4 percentage points in the probability of a child being fully vaccinated, with effects more pronounced among the poor. PBF improved the utilization and quality of most maternal and child care, mainly among the better off, but did not improve targeting of unmet needs for ANC. Especially types of care which require a behavioral change of health care workers when the patient is already in the clinic show improvements. Improvements are smaller for services which require effort from the provider to change patients' utilization choices.

A population-based study of neonatal mortality and maternal care utilization in the Indian state of Bihar.

BackgroundA substantial reduction in neonatal deaths is required in India to meet the Millennium Development Goal of a two-thirds reduction in child mortality by 2015. We report neonatal mortality estimates and utilisation of maternal care in the Indian state of Bihar.MethodsA representative population-based sample of 14,293 women who had a live birth in the last 12 months based on multistage sampling from all 38 districts of Bihar was selected for interview in early 2012. We estimated neonatal mortality rate and its associations using multiple logistic regression, assessed maternal care coverage and its inequality by wealth index, and retention of mothers in the health system for the full sequence of maternal care services.ResultsNeonatal mortality rate for Bihar was 32.2 (95% confidence interval [CI] 27.6-36.8) per 1,000 live births. Postnatal care related variables were significantly associated with neonatal deaths – no delayed bathing of new born (odds ratio [OR] 3.45, 95% CI 2.47-4.81) and no kangaroo care immediately after birth (OR 2.20, 95% CI 1.49-3.25). History of maternal complications and delivery in a private sector health facility had nearly twice the odds of neonatal death; the latter was driven by the very high neonatal mortality associated with private facility delivery in the lower two wealth index quartiles. A pattern of mass deprivation was seen for coverage of 4 or more ANC visits, health facility delivery and postnatal care for the same woman, with only 5.2% of women receiving this overall; this coverage was low for the highest wealth index quartile as well at 12.2%. Coverage of 4 or more ANC visits was 7.4% and 27.7% in the lowest and the highest wealth quartiles, respectively. Giving birth in a health facility was reported by 49.5% of women in the lowest wealth index quartile and by 77.7% in the highest quartile. Only 21.2% women reported post-natal care within 2 weeks of delivery in the lowest wealth index quartile, and 42.2% in the highest quartile.ConclusionsNeonatal mortality continues to be relatively high in Bihar, and the utilization of maternal care very low and inequitable. Interventions need to address these deficiencies.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2393-14-357) contains supplementary material, which is available to authorized users.

Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: findings from the 2010 National Maternity Survey.

The objective of this analysis was to explore the healthcare-seeking behaviours and experiences of maternity care among women from different socio-economic groups in order to improve understanding of why socially disadvantaged women have poorer maternal health outcomes in the UK. Secondary analysis of a national survey of women conducted 3 months after they had given birth. England. A total of 5332 women. Logistic regression analysis to investigate differences in outcomes among different socio-economic groups, classified by the Index of Multiple Deprivation (IMD). Healthcare-seeking behaviours, outcomes and experiences of maternity care. With each increase in IMD quintile (decrease in socio-economic position), women were shown to be 25% (adjusted odds ratio [aOR] 0.75; 95% confidence interval [95% CI] 0.63-0.90) less likely to have had any antenatal care and 15% (aOR 0.85; 95% CI 0.80-0.90) less likely to have had a routine postnatal check-up. They were 4% (aOR 1.04; 95% CI 0.99-1.10) more likely to have had an antenatal hospital admission, 7% (aOR 1.07; 95% CI 0.99-1.16) more likely to have been transferred during labour and 4% (aOR 1.04; 95% CI 0.99-1.09) more likely to have had a caesarean birth, although these results were not statistically significant. With decreasing socio-economic position women were more likely to report that they were not treated respectfully or spoken to in a way they could understand by doctors and midwives. This analysis suggests the need for a focusing of professionals and services towards pregnant women from lower socio-economic groups and more targeted maternal public health education towards socially disadvantaged women.

Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review.

BackgroundAlthough disabled women are significantly more likely to experience domestic abuse during pregnancy than non-disabled women, very little is known about how maternity care access and utilisation is affected by the co-existence of disability and domestic abuse. This systematic review of the literature explored how domestic abuse impacts upon disabled women’s access to maternity services.MethodsEleven articles were identified through a search of six electronic databases and data were analysed to identify: the factors that facilitate or compromise access to care; the consequences of inadequate care for pregnant women’s health and wellbeing; and the effectiveness of existing strategies for improvement.ResultsFindings indicate that a mental health diagnosis, poor relationships with health professionals and environmental barriers can compromise women’s utilisation of maternity services. Domestic abuse can both compromise, and catalyse, access to services and social support is a positive factor when accessing care. Delayed and inadequate care has adverse effects on women’s physical and psychological health, however further research is required to fully explore the nature and extent of these consequences. Only one study identified strategies currently being used to improve access to services for disabled women experiencing abuse.ConclusionsBased upon the barriers and facilitators identified within the review, we suggest that future strategies for improvement should focus on: understanding women’s reasons for accessing care; fostering positive relationships; being women-centred; promoting environmental accessibility; and improving the strength of the evidence base.

Evaluating health care delivery reform initiatives in the face of "cost disease".

The authors analyzed historical claims data from 2007 to 2011 from the Vermont All-Payer Claims database for all individuals covered by commercial insurance and Medicaid to determine per capita inpatient expenditures, cost per discharge, and cost per inpatient day. The authors further evaluated the proportion of all health care expenditure allocated to mental health, maternity care, surgical services, and medical services. Although utilization of inpatient services declined during the study period, cost per discharge and cost per inpatient day increased in a compensatory manner. Although the utilization of inpatient services by the Medicaid population decreased by 8%, cost per discharge increased by 84%. Among the commercially insured, discharges per 1000 members were essentially unchanged during the study period and inpatient cost per discharge increased by a relatively modest 32%. The relative utilization of mental health, maternity care, surgical services, and medical services was unchanged during the study period. The significant increase in the cost of inpatient services increased the proportion of total expenditure on surgical services from 21% in 2007 to 33% in 2011. The authors conclude that although health care providers are increasingly being assessed on their ability to control health care costs while achieving better outcomes, there are many cost drivers that are outside of their control. Efforts to assess initiatives, such as patient-centered medical homes, should be focused on utilization trends and outcomes rather than cost or, at a minimum, reflect cost drivers that physicians and other providers cannot influence.

Effects of Out-of-Pocket Payments on Access to Maternal Health Services in Almaty, Kazakhstan: A Qualitative Study

The current study addresses health care reform in transitional countries and explores the impact of out-of-pocket payments on access to maternal health services drawing on Kazakhstan's case. Data on out-of-pocket payments and access to maternity care were generated through qualitative in-depth interviews conducted in Almaty during the period 2009–2010. The results indicate that while health sector reform was designed to improve the quality of care and equity, the introduction of official user charges accompanied by a rapid growth of informal payments created financial barriers that prevented women from accessing maternal services leading to reduction in utilisation of maternity care.

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review.

BackgroundDemand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.MethodsThe protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.ResultsThirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.ConclusionsDemand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

Evolution of quality in maternal health in India: Lessons and priorities

Background: Quality of care is central to current efforts under National Rural Health Mission (NRHM) in India to sustain gains in utilization of institutional maternal and newborn care. For effective planning around institutionalizing quality improvement systems, it is important to critically evaluate India's maternal health policy and services in historical perspective. Objectives: The narrative review was conducted (i) to trace the evolution of concern with quality in maternal health in the context of health system development in India from independence (1947) to the present; and (ii) identify quality-related issues and areas for further action to improve maternal and infant survival outcomes. Materials and Methods: Peer reviewed scientific publications were identified through systematic searches of scientific databases, grey literature and policy documents. Altogether 174 documents were reviewed. Prospectively designed forms extracted data on (i) health system and quality development; (ii) service performance; (iii) health and safe delivery outcomes. Results: In the first four decades after independence, concerns with infrastructure expansion and vertical disease eradication programmes neglected quality of maternal healthcare in India. With growing concern for quality, strategies addressing this were incorporated in NRHM launched in 2005, including public health standards and quality assurance system in reproductive and child health services. Conclusion: Focus on quality in maternal health in India has increased in recent years, especially under NRHM, and this has helped accelerate progress in maternal and neonatal outcomes. Further action areas include the need to increase funding, match rising demand with quality services and enhance functioning of quality assurance system.

Association between Maternal Preventive Care Utilization and Adolescent Vaccination: It's Not Just About Pap Testing

Study ObjectiveTo examine the association between maternal preventive care utilization and human papillomavirus (HPV) vaccine uptake by their adolescent daughters. DesignA cross-sectional study using immunization records from administrative claims and the state health department's immunization information system from June 2006 through May 2011. ParticipantsCommercially-insured Michigan females aged 13-17 in May 2011 and their mothers. Mothers were identified using relationship information on the insurance contract. Main Outcome MeasuresUsing logistic regression, we investigated whether initiating and/or completing the HPV vaccine series were associated with maternal preventive care utilization (Papaniculou testing, mammograms, primary care office visits) independently and using a combined maternal preventive care utilization index. ResultsAmong 38,604 mother-daughter pairs, 36% of daughters initiated and 22% completed the HPV vaccine series. Maternal utilization of each recommended service was modestly associated with both daughter's initiation and completion of the HPV vaccine. Effect estimates for receipt of Papaniculou test on vaccine initiation (OR = 1.07, 95% CI = 1.06-1.08) were not any higher than for mammograms (OR = 1.10, 95% CI = 1.08-1.11) or primary care office visits (OR = 1.07, 95% CI = 1.06-1.09). Using a maternal preventive care utilization index, vaccine uptake increased with an increasing number of received services. ConclusionsMaternal receipt of recommended preventive care, which may reflect general attitudes toward prevention, is as or more predictive of daughter's vaccination status than cervical cancer screening alone. Engaging women in broad routine preventive care practices may have additional positive effects on adolescent HPV vaccination beyond those achieved through cervical cancer prevention efforts alone.

Do cesarean deliveries on maternal request lead to greater maternal care utilization during six-month, one-year, and two-year postpartum periods? Evidence from NHI claims data in Taiwan

ObjectiveThe purpose of the study is to examine whether women who have undergone cesarean deliveries on maternal request (CDMR) have a higher utilization of outpatient and inpatient obstetric and gynecological services than do those with vaginal deliveries (VD). MethodsWe use two population-based claims datasets to trace the six-month, one-year, and two-year postpartum periods (PP) medical care utilizations by women who have undergone CDMRs or VDs during 2002 in Taiwan. The paper analyses the utilization of services through logistic, negative binomial, linear, and log-linear regressions based on the data types. ResultsWe find that CDMRs are associated with a greater utilization of medical care than are VDs. Compared to mothers who have undergone VDs, those who underwent CDMRs have a greater likelihood to have additional outpatient visits (by 9.6% for six-month PP and 7.5% for one-year PP) and re-hospitalization (by 0.24%, 0.3%, and 0.66% for the three PPs, respectively), more outpatient revisits (by 0.47, 0.66, and 1.07, respectively), greater outpatient expenditure (by NT$324 for one-year PP) and inpatient expenditure (by NT$6178, NT$5992, and NT$5484, respectively). ConclusionCesarean deliveries on maternal request lead to significant negative outcomes during the postpartum period, which should be taken into account in the cost-benefit calculation.

National health insurance, social influence and antenatal care use in Ghana

The study explores the importance of social influence and the availability of health insurance on maternal care utilization in Ghana through the use of antenatal care services. A number of studies have found that access to health insurance plays a critical role in women’s decision to utilize antenatal care services. However, little is known about the role that social forces play in this decision. This study uses village-level data from the 2008 Ghana Demographic and Health Survey to investigate the effects of health insurance and social influences on the intensity of antenatal care utilization by Ghanaian women. Using GIS information at the village level, we employ a spatial lag regression model in this study. Results indicate that, controlling for a host of socioeconomic and geographical factors, women who have health insurance appear to use more antenatal services than women who do not. In addition, the intensity of antenatal visits appears to be spatially correlated among the survey villages, implying that there may be some social influences that affect a woman’s decision to utilize antenatal care. A reason for this may be that women who benefit from antenatal care through positive pregnancy outcomes may pass this information along to their peers who also increase their use of these services in response. Traditional/Cultural leaders as “gate-keepers” may be useful in the dissemination of maternal health care information. Public health officials may also explore the possibility of disseminating information relating to maternal care services via the mass media.

Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis

BackgroundThe evaluation of all potential sources of low skilled maternal care utilization is crucial for Ethiopia. Previous studies have largely disregarded the contribution of different levels. This study was planned to assess the effect of individual, communal, and health facility characteristics in the utilization of antenatal, delivery, and postnatal care by a skilled provider.MethodsA linked facility and population-based survey was conducted over three months (January - March 2012) in twelve “kebeles” of North Gondar Zone, Amhara Region. A total of 1668 women who had births in the year preceding the survey were selected for analysis. Using a multilevel modelling, we examined the effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization.ResultAbout 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services.ConclusionFactors operating at individual and “kebele” levels play a significant role in determining utilization of skilled maternal health services. Interventions to create better community awareness and perception about skilled providers and their care, and ensuring the seamless performance of health care facilities have been considered crucial to improve skilled maternal services in the study area. Such interventions should target underprivileged women.

Effectiveness of an intervention on uptake of maternal care in four counties in Ningxia, China

To understand the utilisation of prenatal care and hospitalised delivery among pregnant Muslim women in Ningxia, China, and to explore the effectiveness of the integrated interventions to reduce maternal mortality. Cross-sectional surveys before and after the intervention were carried out. Using multistage sampling, 1215 mothers of children <5 years old were recruited: 583 in the pre-intervention survey and 632 in the post-intervention study. Data on prenatal care and delivery were collected from face-to-face interviews. Maternal mortality ratio (MMR) data were obtained from the local Maternal and Child Mortality Report System. After the intervention, the MMR significantly decreased (45.5 deaths per 100,000 live births to 32.7 deaths). Fewer children were born at home after the intervention than before the intervention (OR, 0.11; 95% CI, 0.08-0.15). The proportion of women who attended prenatal care at least once increased from 78.2% to 98.9% (OR, 24.55; 95% CI, 11.37-53.12). The proportion of women who had prenatal visit(s) in the first trimester of pregnancy increased from 35.1% to 82.6% (OR, 8.77; 95% CI, 6.58-11.69). The quality of prenatal care was greatly improved. Effects of the intervention on the utilisation of maternal care remained significant after adjusting for education level and household possessions. The findings suggest that integrated strategies can effectively reduce maternal mortality.

Out-of-pocket expenditure on institutional delivery in India

Though promotion of institutional delivery is used as a strategy to reduce maternal and neonatal mortality, about half of the deliveries in India are conducted at home without any medical care. Among women who deliver at home, one in four cites cost as barrier to facility-based care. The relative share of deliveries in private health centres has increased over time and the associated costs are often catastrophic for poor households. Though research has identified socio-economic, demographic and geographic barriers to the utilization of maternal care, little is known on the cost differentials in delivery care in India. The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India. The study utilizes unit data from the District Level Household and Facility Survey (DLHS-3), conducted in India during 2007-08. Descriptive statistics, principal component analyses and a two-part model are used in the analyses. During 2004-08, the mean OOP expenditure for a delivery in a public health centre in India was US$39 compared with US$139 in a private health centre. The predicted expenditure for a caesarean delivery was six times higher than for a normal delivery. With an increase in the economic status and educational attainment of mothers, the propensity and rate of OOP expenditure increases, linking higher OOP expenditure to quality of care. The OOP expenditure in public health centres, adjusting for inflation, has declined over time, possibly due to increased spending under the National Rural Health Mission. Based on these findings, we recommend that facilities in public health centres of poorly performing states are improved and that public-private partnership models are developed to reduce the economic burden for households of maternal care in India.