Evidence from low and middle income countries (LMICs) suggests that maternal mortality is more prevalent among the poor whereas access to maternal health services is concentrated among the rich. In Bangladesh substantial inequities exist both in the use of facility-based basic obstetric care and for home births attended by skilled birth attendant. BRAC initiated an intervention on Improving Maternal, Neonatal, and Child Survival (IMNCS) in the rural areas of Bangladesh in 2008. One of the objectives of the intervention is to improve the utilization of maternal and child health care services among the poor. This study aimed to look at the impact of the intervention on utilization and also on equity of access to maternal health services.
A quasi-experimental pre-post comparison study was conducted in rural areas of five districts comprising three intervention (Gaibandha, Rangpur and Mymensingh) and two comparison districts (Netrokona and Naogaon). Data on health seeking behaviour for maternal health were collected from a repeated cross sectional household survey conducted in 2008 and 2010.
Results show that the intervention appears to cause an increase in the utilization of antenatal care. The concentration index (CI) shows that this has become pro-poor over time (from CI: 0.30 to CI: 0.04) in the intervention areas. In contrast the use of ANC from medically trained providers has become pro-rich (from, CI: 0.18 to CI: 0.22). There was a significant increase in the utilisation of trained attendants for home delivery in the intervention areas compared to the comparison areas and the change was found to be pro-poor. Use of postnatal care cervices was also found to be pro-poor (from CI: 0.37 to CI: 0.14). Utilization of ANC services provided by medically trained provider did not improve in the intervention area. However, where the intervention had a positive effect on utilization it also seemed to have had a positive effect on equity.
To sustain equity in health care utilization, the IMNCS programme needs to continue providing free home based services. In addition to this, the programme should also continue to provide funding to bear the cost to those mothers who are not able to have the comprehensive ANC from medically trained providers.
Maternal mortality is a major public health problem in low-income countries, such as Bangladesh. Women's empowerment in relation to enhanced utilization of delivery care is underexplored. This study investigates the associations between women's economic empowerment and their utilization of maternal health care services in Bangladesh.
In total, 4925 women (15–49 years of age) with at least one child from whole Bangladesh constituted the study sample. Home delivery without skilled birth attendant and use of institutional delivery services were the main outcome variables used for the analyses. Economic empowerment, neighborhood socioeconomic status, household economic status, and demographic factors were considered as explanatory variables. The chi square test and unadjusted and adjusted logistic regression analyses were applied at the collected data.
In the adjusted model, respondent's and husband's education, household economic status, and residency emerged as important predictors for utilization of delivery care services. In the unadjusted model, economically empowered working and microfinanced women displayed more home delivery.
The current study shows that use of delivery care services is associated with socioeconomic development and can be enhanced by societies that focus on general issues such as schooling, economic wellbeing, and gender-based discrimination.
Empowerment; home delivery; maternal mortality; neighborhood socioeconomic status
Women in both Bangladesh and Uganda face a number of barriers to delivery in professional health facilities, including costs, transportation problems, and sociocultural norms to deliver at home. Some women in both the countries manage to overcome these barriers. This paper reports on a comparative qualitative study investigating how some women and their families were able to use professional delivery services. The study provides insights into the decision-making processes and overcoming access barriers. Husbands were found to be particularly important in Uganda, while, in Bangladesh, a number of individuals could influence care-seeking, including unqualified local healers or traditional birth attendants. In both the settings, cost and transport barriers were often overcome through social networks. Social prohibitions on birth in the health facility did not feature strongly in women's accounts, with several Ugandan women explaining that friends or peers also used facilities, while, in Bangladesh, perceived complications apparently justified the use of professional medical care. Investigating the ways in which some women can overcome common barriers can help inform policy and planning to increase the use of health facilities for child delivery.
Maternal health; Delivery; Health services; Healthcare; Health facilities; Comparative studies; Uganda; Bangladesh
Recognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC.
This cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. Pearson's chi-square test, t-test and Mann-Whitney test were performed.
The median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in income-generating activities.
Manoshi program reduces the first delay for life-threatening conditions but not non-life-threatening complications even though providing financial assistance. Programme should give more emphasis on raising awareness through couple/family-based education about maternal complications and dispel fear of clinical care to accelerate seeking EmOC.
While India has made significant progress in reducing maternal mortality, attaining further declines will require increased skilled birth attendance and institutional delivery among marginalized and difficult to reach populations.
A population-based survey was carried out among 16 randomly selected rural villages in rural Mysore District in Karnataka, India between August and September 2008. All households in selected villages were enumerated and women with children 6 years of age or younger underwent an interviewer-administered questionnaire on antenatal care and institutional delivery.
Institutional deliveries in rural areas of Mysore District increased from 51% to 70% between 2002 and 2008. While increasing numbers of women were accessing antenatal care and delivering in hospitals, large disparities were found in uptake of these services among different castes. Mothers belonging to general castes were almost twice as likely to have an institutional birth as compared to scheduled castes and tribes. Mothers belonging to other backward caste or general castes had 1.8 times higher odds (95% CI: 1.21, 2.89) of having an institutional delivery as compared to scheduled castes and tribes. In multivariable analysis, which adjusted for inter- and intra-village variance, Below Poverty Line status, caste, and receiving antenatal care were all associated with institutional delivery.
The results of the study suggest that while the Indian Government has made significant progress in increasing antenatal care and institutional deliveries among rural populations, further success in lowering maternal mortality will likely hinge on the success of NRHM programs focused on serving marginalized groups. Health interventions which target SC/ST may also have to address both perceived and actual stigma and discrimination, in addition to providing needed services. Strategies for overcoming these barriers may include sensitization of healthcare workers, targeted health education and outreach, and culturally appropriate community-level interventions. Addressing the needs of these communities will be critical to achieving Millennium Development Goal Five by 2015.
Reproductive health; Millennium Development Goals; Maternal mortality; India; Women's health
Delay in decision-making to use skilled care during pregnancy and childbirth is an important factor for maternal death in many developing countries. This paper examines how decisions for maternal care are made in two rural communities in Burkina Faso.
Focus group discussions (FGDs) and individual interviews (IDIs)) were used to collect information with 30 women in Ouargaye and Diapaga medical districts. All interviews were tape recorded and analyzed using QSR Nvivo 2.0.
Decision-making for use of obstetric care in the family follows the logic of the family’s management. Husbands, brothers-in-law and parents-in-law make the decision about whether to use a health facility for antenatal care or for delivery. In general, decision-makers are those who can pay, including the woman herself. Payment of care is the responsibility of men, according to women interviewed, because of their social role and status.
To increase use of health facilities in Ouargaye and Diapaga, the empowerment of women could be helpful as well as exemption of fees or cost sharing for care.
Decision-making process; Maternal care; Rural medical district; Burkina Faso
Surmang, Qinghai Province is a rural nomadic Tibetan region in western China recently devastated by the 2010 Yushu earthquake; little information is available on access and coverage of maternal and child health services.
A cross-sectional household survey was conducted in August 2004. 402 women of reproductive age (15-50) were interviewed regarding their pregnancy history, access to and utilization of health care, and infant and child health care practices.
Women's access to education was low at 15% for any formal schooling; adult female literacy was <20%. One third of women received any antenatal care during their last pregnancy. Institutional delivery and skilled birth attendance were <1%, and there were no reported cesarean deliveries. Birth was commonly attended by a female relative, and 8% of women delivered alone. Use of unsterilized instrument to cut the umbilical cord was nearly universal (94%), while coverage for tetanus toxoid immunization was only 14%. Traditional Tibetan healers were frequently sought for problems during pregnancy (70%), the postpartum period (87%), and for childhood illnesses (74%). Western medicine (61%) was preferred over Tibetan medicine (9%) for preventive antenatal care. The average time to reach a health facility was 4.3 hours. Postpartum infectious morbidity appeared to be high, but only 3% of women with postpartum problems received western medical care. 64% of recently pregnant women reported that they were very worried about dying in childbirth. The community reported 3 maternal deaths and 103 live births in the 19 months prior to the survey.
While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in Surmang suffer from substantial health inequities in access to antenatal, skilled birth and postpartum care. Institutional delivery, skilled attendance and cesarean delivery are virtually inaccessible, and consequently maternal and infant morbidity and mortality are likely high. Urgent action is needed to improve access to maternal, neonatal and child health care in these marginalized populations. The reconstruction after the recent earthquake provides a unique opportunity to link this population with the health system.
Tibetan; Qinghai; Yushu; China; facility delivery; institutional delivery; maternal morbidity; maternal mortality; maternal health; child health; newborn health; Yushu earthquake
Bangladesh is committed to the fifth Millennium Development Goal (MDG-5) target of reducing its maternal mortality ratio by three-quarters between 1990 and 2015. Since the early 1990s, Bangladesh has followed a strategy of improving access to facilities equipped and staffed to provide emergency obstetric care (EmOC).
We used data from four Demographic and Health Surveys conducted between 1993 and 2004 to examine trends in the proportions of live births preceded by antenatal consultation, attended by a health professional, and delivered by caesarean section, according to key socio-demographic characteristics.
Utilization of antenatal care increased substantially, from 24% in 1991 to 60% in 2004. Despite a relatively greater increase in rural than urban areas, utilization remained much lower among the poorest rural women without formal education (18%) compared with the richest urban women with secondary or higher education (99%). Professional attendance at delivery increased by 50% (from 9% to 14%, more rapidly in rural than urban areas), and caesarean sections trebled (from 2% to 6%), but these indicators remained low even by developing country standards. Within these trends there were huge inequalities; 86% of live births among the richest urban women with secondary or higher education were attended by a health professional, and 35% were delivered by caesarean section, compared with 2% and 0.1% respectively of live births among the poorest rural women without formal education. The trend in professional attendance was entirely confounded by socioeconomic and demographic changes, but education of the woman and her husband remained important determinants of utilization of obstetric services.
Despite commendable progress in improving uptake of antenatal care, and in equipping health facilities to provide emergency obstetric care, the very low utilization of these facilities, especially by poor women, is a major impediment to meeting MDG-5 in Bangladesh.
Delay in accessing emergency obstetric-care facilities during life-threatening obstetric complications is a significant determinant of high maternal mortality in developing countries. To examine the factors associated with delays in seeking care for episodes of serious illness and their possible implications for safe motherhood interventions in rural Bangladesh, a cross-sectional study was initiated in Matlab sub-district on the perceptions of household heads regarding delays in seeking care for episodes of serious illness among household members. Of 2,177 households in the study, 881 (40.5%) reported at least one household member who experienced an illness perceived to be serious enough to warrant care-seeking either from health facilities or from providers. Of these, 775 (88.0%) actually visited some providers for treatment, of whom 79.1% used transport. Overall, 69.3% perceived a delay in deciding to seek care, while 12.1% and 24.6% perceived a delay in accessing transport and in reaching the provider respectively. The median time required to make a decision to seek care was 72 minutes, while the same was 10 minutes to get transport and 80 minutes to reach a facility or a provider. Time to decide to seek care was shortest for pregnancy-related conditions and longest for illnesses classified as chronic, while time to reach a facility was longest for pregnancy-related illnesses and shortest for illnesses classified as acute. However, the perceived delay in seeking care did not differ significantly across socioeconomic levels or gender categories but differed significantly between those seeking care from informal providers compared to formal providers. Reasons for the delay included waiting time for results of informal treatment, inability to judge the graveness of disease, and lack of money. For pregnancy-related morbidities, 45% reported ‘inability to judge the graveness of the situation’ as a reason for delay in making decision. After controlling for possible confounders in multivariate analysis, type of illness and facility visited were the strongest determinants of delay in making decision to seek care. To reduce delays in making decision to seek care in rural Bangladesh, safe motherhood interventions should intensify behaviour change-communication efforts to educate communities to recognize pregnancy-danger signs for which a prompt action must be taken to save life. This strategy should be combined with efforts to train community-based skilled birth attendants, upgrading public facilities to provide emergency obstetric care, introduce voucher schemes to improve access by the poorest of the poor, and improve the quality of care at all levels.
Healthcare; Emergency obstetric care; Behaviours; Maternal mortality; Interventions; Safe motherhood; Cross-sectional studies; Bangladesh
Evidence show that lack of access to and use of, essential obstetric care services to be a crucial factor that contributes to the high maternal morbidity and mortality. Skilled attendance during labor, delivery and early post-partum period could reduce deaths due to obstructed labor, hemorrhage, sepsis and eclampsia. There is limited information on the mothers' use of skilled delivery services in the study area. This study assessed the predictors of safe delivery service utilization in Arsi Zone, Southeast Ethiopia.
A cross- sectional community based study using quantitative and qualitative methods was conducted from February 15th to March 15th 2006. A total of 1089 women who had at least one birth one year prior to the study were involved in the study from nine rural and four urban kebeles in three Woredas (Districts) selected using a systematic sampling method from all households in the study area. A pre-tested structured interviewer administered questionnaire was used to collect data. Information on the utilization of safe delivery service and socio-demographic, individual and institutional factors and past obstetric history were collected. Focus Group Discussion guide was used for qualitative data collection. The data were edited, cleaned, and entered into a computer and analyzed using SPSS for windows version 12.0.
One thousand seventy four women who had at least one birth were interviewed making a response rate 98.6%. Two hundred seventy one (75.0%) of urban and 373(52.0%) rural women received antenatal care from skilled health professional at least once during their last pregnancy. Thirty-one (4.3%) of rural and 145 (40.4%) of urban women delivered in health institution. In multivariate analysis showed that residential area OR= 8.5, 95%CI; (5.1,13.9), parity OR=0.18, 95%CI; (0.08, 0.42), and ANC service use OR= 4.5, 95%CI; (2.2,8.9), and maternal education OR=4.6, 95%CI; (1.7,12.8), were most significant predictors of safe delivery service use by mothers (P< 0.01).
Birth attended by skilled personnel was low in the study area. Maternal education, her birth experience and her use of prenatal services are important predictors. Promoting information, education and communication on safe delivery service utilization, expansion of health service and empowerment of women are needed.
safe delivery; skilled attendants; maternal health service utilization
Background. Utilization of professional care during childbirth by women in low-income countries is important for the progress towards MDG 5. In Yemen, home births have decreased minimally during the past decades. Objective. The study investigates the influence of socio-demographic, birth outcome and demand factors on women's future preference of a home or institutional childbirth. Method. We interviewed 220 women with childbirth experience in urban/rural Yemen. We performed bivariate chi-square tests and multiple logistic regression analysis. A multistage sampling process was used. Results. The issues of own choice, birth support and birth complications were the most important for women's preference of future location of childbirth. Women who had previously been able to follow their own individual choice regarding birth attendance and/or location of childbirth were six times more likely to plan a future childbirth in the same location and women who received birth support four times more likely. Birth complications were associated with a 2.5-fold decrease in likelihood. Conclusions. To offer women with institutional childbirth access to birth support is crucial in attracting women to professional care during childbirth. Yemeni women's low utilization of modern delivery care should be seen in the context of women's low autonomy and status.
Pakistan has high maternal mortality, particularly in the rural areas. The delay in decision making to seek medical care during obstetric emergencies remains a significant factor in maternal mortality.
We present results from an experimental study in rural Pakistan. Village clusters were randomly assigned to intervention and control arms (16 clusters each). In the intervention clusters, women were provided information on safe motherhood through pictorial booklets and audiocassettes; traditional birth attendants were trained in clean delivery and recognition of obstetric and newborn complications; and emergency transportation systems were set up. In eight of the 16 intervention clusters, husbands also received specially designed education materials on safe motherhood and family planning. Pre- and post-intervention surveys on selected maternal and neonatal health indicators were conducted in all 32 clusters. A district-wide survey was conducted two years after project completion to measure any residual impact of the interventions.
Pregnant women in intervention clusters received prenatal care and prophylactic iron therapy more frequently than pregnant women in control clusters. Providing safe motherhood education to husbands resulted in further improvement of some indicators. There was a small but significant increase in percent of hospital deliveries but no impact on the use of skilled birth attendants. Perinatal mortality reduced significantly in clusters where only wives received information and education in safe motherhood. The survey to assess residual impact showed similar results.
We conclude that providing safe motherhood education increased the probability of pregnant women having prenatal care and utilization of health services for obstetric complications.
Maternal mortality among poor rural women in the Lao People’s Democratic Republic (Lao PDR) is among the highest in Southeast Asia, in part because only 15% give birth at health facilities. This study explored why women and their families prefer home deliveries to deliveries at health facilities.
A qualitative study was conducted from December 2008 to February 2009 in two provinces of Lao PDR. Data was collected through eight focus group discussions (FGD) as well as through in-depth interviews with 12 mothers who delivered at home during the last year, eight husbands and eight grandmothers, involving a total of 71 respondents. Content analysis was used to analyze the FGD and interview transcripts.
Obstacles to giving birth at health facilities included: (1) Distance to the health facilities and difficulties and costs of getting there; (2) Attitudes, quality of care, and care practices at the health facilities, including a horizontal birth position, episiotomies, lack of privacy, and the presence of male staff; (3) The wish to have family members nearby and the need for women to be close to their other children and the housework; and (4) The wish to follow traditional birth practices such as giving birth in a squatting position and lying on a “hot bed” after delivery. The decision about where to give birth was commonly made by the woman’s husband, mother, mother-in-law or other relatives in consultation with the woman herself.
This study suggests that the preference in rural Laos for giving birth at home is due to convenience, cost, comfort and tradition. In order to assure safer births and reduce rural Lao PDR’s high maternal mortality rate, health centers could consider accommodating the wishes and traditional practices of many rural Laotians: allowing family in the birthing rooms; allowing traditional practices; and improving attitudes among staff. Traditional birth attendants, women, and their families could be taught and encouraged to recognize the signs of at-risk pregnancies so as to be able to reach health facilities on time.
Among the factors contributing to the high maternal morbidity and mortality in Uganda is the high proportion of pregnant women who do not deliver under supervision in health facilities. This study aimed to identify the independent predictors of health facility delivery in Busia a rural district in Uganda with a view of suggesting measures for remedial action.
In a cross sectional survey, 500 women who had a delivery in the past two years (from November 16 2005 to November 15 2007) were interviewed regarding place of delivery, demographic characteristics, reproductive history, attendance for antenatal care, accessibility of health services, preferred delivery positions, preference for disposal of placenta and mother’s autonomy in decision making. In addition the household socio economic status was assessed. The independent predictors of health facility delivery were identified by comparing women who delivered in health facilities to those who did not, using bivariate and binary logistic regression analysis.
Eight independent predictors that favoured delivery in a health facility include: being of high socio-economic status (adjusted odds ratio [AOR] 2.8 95% Confidence interval [95% CI]1.2–6.3), previous difficult delivery (AOR 4.2, 95% CI 3.0–8.0), parity less than four (AOR 2.9, 95% CI 1.6–5.6), preference of supine position for second stage of labour (AOR 5.9, 95% CI 3.5–11.1) preferring health workers to dispose the placenta (AOR 12.1, 95% CI 4.3–34.1), not having difficulty with transport (AOR 2.0, 95% CI 1.2–3.5), being autonomous in decision to attend antenatal care (AOR 1.9, 95% CI 1.1–3.4) and depending on other people (e.g. spouse) in making a decision of where to deliver from (AOR 2.4, 95% CI 1.4–4.6). A model with these 8 variables had an overall correct classification of 81.4% (chi square = 230.3, P < 0.001).
These data suggest that in order to increase health facility deliveries there is need for reaching women of low social economic status and of higher parity with suitable interventions aimed at reducing barriers that make women less likely to deliver in health units such as ensuring availability of transport and involving spouses in the birth plan.
Home deliveries; Male involvement; Birth plan; Sub-Saharan Africa
This study explored violence against women with chronic maternal disabilities in rural Bangladesh. During November 2006–July 2008, in-depth interviews were conducted with 17 rural Bangladeshi women suffering from uterine prolapse, stress incontinence, or fistula. Results of interviews showed that exposure to emotional abuse was almost universal, and most women were sexually abused. The common triggers for violence were the inability of the woman to perform household chores and to satisfy her husband's sexual demands. Misconceptions relating to the causes of these disabilities and the inability of the affected women to fulfill gender role expectations fostered stigma. Emotional and sexual violence increased their vulnerability, highlighting the lack of life options outside marriage and silencing most of them into accepting the violence. Initiatives need to be developed to address misperceptions regarding the causes of such disabilities and, in the long-term, create economic opportunities for reducing the dependence of women on marriage and men and transform the society to overcome rigid gender norms.
Emotional violence; Maternal disabilities; Maternal morbidity; Sexual violence; Bangladesh
The aim of this study was to examine the prevalence of maternal and newborn-care practices among women reporting a birth in the previous year in three districts in different divisions of Bangladesh. In 2003, 6,785 women, who had delivered a newborn infant in the previous year, across three districts in Bangladesh, were interviewed. Overall, less than half of the women received any antenatal care, and 11% received a minimum of four check-ups. Only 18% took iron tablets for at least four months during pregnancy. Over 90% of the 6,785 deliveries took place at home, and only 11% were attended either by a doctor or by a nurse. The mothers reported three key hygienic practices in 54% of deliveries: attendants washing their hands with soap and boiling cord-tie and blade for cutting the cord. Forty-four percent of the 6,785 infants were bathed immediately after delivery, and 42% were given colostrum as their first food. The results suggest that maternal and newborn-care remains a cause of concern in rural Bangladesh. Short-term policies to promote healthy behaviour in the home are needed, in addition to the long-term goal of skilled birth attendance.
Pregnancy; Safe motherhood; Newborn care; Healthcare-seeking behaviour; Cross-sectional studies; Retrospective studies; Baseline surveys; Bangladesh
Globally, over 500,000 females die of complications related to pregnancy and childbirth each year, and of these, over 99% of deaths occur in developing countries such as Uganda. Utilisation of modern and professional care during delivery is important in lowering maternal mortality. This paper sets out to investigate the factors associated with the utilisation of modern and professional childbirth care so as to inform policy makers on the pertinent factors that need to be influenced by policy.
A nationally representative Uganda Demographic and Health Survey (UDHS) (2006) was used. Sampling was done in two stages. In the first stage 321 clusters were selected from a list of clusters sampled in the 2005/06 Uganda National Household Survey (UNHS), 17 clusters from the 2002 Census frame from Karamoja, and 30 internally displaced camps (IDPs). In the second stage, the households in each cluster were selected as per the UNHS listing. In addition an additional 20 households were randomly selected in each cluster. Questionnaires were used during data collection. During the analysis, a maximum likelihood probit technique was employed. Prior to this, a bivariate approach was used to generate average percentages of mothers using the childbirth care services by background characteristics.
It is found that maternal education is the strongest predictor, especially at post-secondary level (highest marginal effect of 33% and P<0.01), associated with the utilisation of childbirth care. Whereas partner's education at all levels is important, maternal education is observed to exert a much stronger association. Other factors significantly associated with the utilisation of professional childbirth care include community infrastructure, occupation, location, and regional differences, wealth status, religion, and age cohorts.
These findings suggest that whereas all levels of education are important, the effects of post-secondary education are more pronounced. Therefore, efforts to improve professional childbirth care utilisation need to focus on female education beyond secondary level. In addition, measures are needed to improve agricultural productivity which might improve earnings and childbirth care utilisation. Government should also undertake to improve community infrastructure across all regions and locations. Both government and donors can ensure universal access to professional childbirth care irrespective of the ability to pay.
Maternal education; childbirth care; Uganda
Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15–49 years in Tigray, Ethiopia.
The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation.
The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation.
A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.
Assistance during delivery by a skilled attendant is recommended as a means to reduce child and maternal mortality. Globally, higher levels of maternal education have been associated with better health behaviours at delivery. However, given that heads of households tend to be the decision makers regarding accessing healthcare, some educated mothers may find themselves prevented from accessing healthcare at the point of delivery.
We examined the association between head of household education level and health seeking behaviours at delivery across a sample of 392 households. Chi-squared analysis and odds ratios were calculated to measure the strength of the relationship between no, some primary, or some secondary or higher education attained by the head of household and the presence or absence of a skilled birth attendant at that child’s birth, and whether the birth took place at a health facility.
Heads of household (n = 392) were predominantly male (93.4% [(90.9%, 95.8%), a = 0.05]). We found a significant difference in skilled birth attendance between heads of households with some primary education and heads of household with some secondary education or higher (χ2 (1) = 6.231, p <0.05) whereby those with secondary or higher education were significantly more likely to seek a skilled birth attendant (OR = 1.5,[1.1,2.1]). The difference in health centre delivery between heads of household with a primary education and heads of household with a secondary or higher education was also significant (χ2 (1) = 7.519, p <0.05). Those with secondary or higher education were significantly more likely to deliver in a health facility (OR = 1.6,[1.2,2.1]).
The results of our analysis, which identified the vast majority of heads of households as men, suggests that education, or rather limited or a lack of education for the head of household, may be a barrier to women’s use of health care in Uganda and therefore reinforces the need to increase educational access among male heads of households. Improving the rates of health centre deliveries and utilization of services provided by skilled health workers might lie, in part, in increasing overall education levels of heads of households, specifically the education of male heads of households.
Skilled birth attendant; Health-centre delivery; Head of household; Education
A husband’s support during childbirth is vital to a parturient woman’s emotional well-being. Evidence suggests that this type of support enables a woman to feel more in control during labour by reducing maternal anxiety during childbirth. However, in Nepal, where childbearing is considered an essential element of a marital relationship, the husband’s role in this process has not been explored. Therefore, we examined whether a woman in Nepal feels more in control during labour when her husband is present, compared to when another woman accompanies her or when she has no support person.
The study participants were low risk primigravida women in the following categories: women who gave birth with their husband present (n = 97), with a female friend present (n = 96), with mixed support (n = 11), and finally, a control group (n = 105). The study was conducted in the public maternity hospital in Kathmandu in 2011. The Labour Agentry Scale (LAS) was used to measure the extent to which women felt in control during labour. The study outcome was compared using an F-test from a one-way analysis of variance, and multiple regression analyses.
The women who gave birth with their husband’s support reported higher mean LAS scores (47.92 ± 6.95) than the women who gave birth with a female friend’s support (39.91 ± 8.27) and the women in the control group (36.68 ± 8.31). The extent to which the women felt in control during labour was found to be positively associated with having their husband’s company during childbirth (β = 0.54; p < 0.001) even after adjusting for background variables. In addition, having a female friend’s company during childbirth was related to the women’s feeling of being in control during labour (β = 0.19; p < 0.001) but the effect size was smaller than for a husband’s company.
The results show that when a woman’s husband is present at the birth, she feels more in control during labour. This finding has strong implications for maternity practices in Nepal, where maternity wards rarely encourage a woman to bring her husband to a pregnancy appointment and to be present during childbirth.
BRAC is implementing a program to improve maternal and newborn health among the urban poor in the slums of Bangladesh (Mansohi), funded by the Bill & Melinda Gates Foundation. Formative research has demonstrated that unqualified allopathic practitioners (UAPs) are commonly assisting home-delivery. The objective of this study was to explore the role of unqualified allopathic practitioners during home delivery in urban slums of Dhaka.
This cross-sectional study was conducted between September 2008 and June 2009 in Kamrangirchar slum in Dhaka, Bangladesh, using both qualitative and quantitative research methods. Through a door-to-door household survey, quantitative data were collected from 463 women with a home birth and/or trial of labor at home. We also conducted seven in-depth interviews with the UAPs to explore their practices.
About one-third (32%) of the 463 women interviewed sought delivery care from a UAP. We did not find an association between socio-demographic characteristics and care-seeking from a UAP, except for education of women. Compared to women with three or more pregnancies, the highest odds ratio was found in the primi-gravidity group [odds ratio (OR): 3.46; 95% confidence interval (CI): 1.65-7.25)], followed by women with two pregnancies (OR: 2.54; 95% CI: 1.36-4.77) to use a UAP. Of women who reported at least one delivery-related complication, 45.2% received care from the UAPs. Of 149 cases where the UAP was involved with delivery care, 133 (89.3%) received medicine to start or increase labor with only 6% (9 of 149) referred by a UAP to any health facility. The qualitative findings showed that UAPs provided a variety of medicines to manage excessive bleeding immediately after childbirth.
There is demand among slum women for delivery-related care from UAPs during home births in Bangladesh. Some UAPs' practices are contrary to current World Health Organization recommendations and could be harmful. Programs need to develop interventions to address these practices to improve perinatal care outcomes.
Assistance by skilled birth attendants (SBAs) during childbirth is one of the strategies aimed at reducing maternal morbidity and mortality in low-income countries. However, the relationship between birth preparedness and decision-making on location of birth and assistance by skilled birth attendants in this context is not well studied. The aim of this study was to assess the influence of birth preparedness practices and decision-making and assistance by SBAs among women in south-western Uganda.
Community survey methods were used to identify 759 recently delivered women from 120 villages in rural Mbarara district. Interviewer-administered questionnaires were used to collect data. Logistic regression analyses were conducted to assess the relationship between birth preparedness, decision-making on location of birth and assistance by SBAs.
35% of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was 68%. The final decision regarding location of birth was made by the woman herself (36%), the woman with spouse (56%) and the woman with relative/friend (8%). The relationships between birth preparedness and women decision-making on location of birth in consultation with spouse/friends/relatives and choosing assistance by SBAs showed statistical significance which persisted after adjusting for possible confounders (OR 1.5, 95% CI: 1.0–2.4) and (OR 4.4, 95% CI: 3.0–6.7) respectively. Education, household assets and birth preparedness showed clear synergistic effect on the relationship between decision-maker on location of birth and assistance by SBAs. Other factors which showed statistical significant relationships with assistance by SBAs were ANC attendance, parity and residence.
Women’s decision-making on location of birth in consultation with spouse/friends/relatives and birth preparedness showed significant effect on choosing assistance by SBAs at birth. Education and household assets ownership showed a synergistic effect on the relationship between the decision-maker and assistance by SBAs.
In countries such as Bangladesh many women may only seek skilled care at birth when complications become evident. This often results in higher neonatal mortality for women who give birth in institutions than for those that give birth at home. However, we hypothesise that this apparent excess mortality is concentrated among less advantaged women. The aim of this paper is to examine the association between place of birth and neonatal mortality in Bangladesh, and how this varies by socio-economic status.
The study is based on pooled data from four Bangladesh Demographic and Household Surveys, and uses descriptive analysis and binomial multivariate logistic regression. It uses regression models stratified for place of delivery to examine the impact of socio-economic status and place of residence on neonatal mortality.
Poor women from rural areas and those with no education who gave birth in institutions had much worse outcomes than those who gave birth at home. There is no difference for more wealthy women. There is a much stronger socio-economic gradient in neonatal mortality for women who gave birth in institutions than those who delivered at home.
In Bangladesh babies from lower socio-economic groups and particularly those in rural areas have very poor outcomes if born in a facility. This suggests poorer, rural and less educated women are failing to obtain the timely access to quality maternal health care services needed to improve newborn outcomes.
Neonatal; Inequalities; Developing countries; Maternal health services; Poverty; Access to health care
Use of maternal health services is an effective means for reducing the risk of maternal morbidity and mortality, especially in places where the general health status of women is poor. This study was guided by the following objectives: 1) To determine the relationship between timing of first antenatal care (ANC) visit and type of delivery assistance 2) To establish the determinants of timing of first ANC visit and type delivery assistance.
Data used were drawn from the 2003 Kenya Demographic and Health Survey, with a focus on young women aged 15-24. The dependent variables were: Timing of first ANC visit coded as "None"; "Late" and "Early", and type of delivery assistance coded as "None"; "Traditional Birth Attendant (TBA)" and "Skilled professional". Control variables included: education, household wealth, urban-rural residence, ethnicity, parity, age at birth of the last child and marital status. Multivariate ordered logistic regression model was used.
The study results show that place of residence, household wealth, education, ethnicity, parity, marital status and age at birth of the last child had strong influences on timing of first ANC visit and the type of delivery assistance received. The major finding is an association between early timing of the first ANC visit and use of skilled professionals at delivery.
This study confirms that timing of first antenatal care is indeed an important entry point for delivery care as young women who initiated antenatal care early were more likely to use skilled professional assistance at delivery than their counterparts who initiated ANC late. The results indicate that a large percentage of young pregnant women do not seek ANC during their first trimester as is recommended by the WHO, which may affect the type of assistance they receive during delivery. It is important that programs aimed at improving maternal health include targeting young women, especially those from rural areas, with low levels of education, higher parity and from poor households, given their high risk during pregnancy. The finding that a considerably high proportion of young women use TBAs as opposed to use of skilled professionals is baffling and calls for further research.
Skilled attendance at childbirth is crucial for decreasing maternal and neonatal mortality, yet many women in low- and middle-income countries deliver outside of health facilities, without skilled help. The main conceptual framework in this field implicitly looks at home births with complications. We expand this to include "preventive" facility delivery for uncomplicated childbirth, and review the kinds of determinants studied in the literature, their hypothesized mechanisms of action and the typical findings, as well as methodological difficulties encountered.
We searched PubMed and Ovid databases for reviews and ascertained relevant articles from these and other sources. Twenty determinants identified were grouped under four themes: (1) sociocultural factors, (2) perceived benefit/need of skilled attendance, (3) economic accessibility and (4) physical accessibility.
There is ample evidence that higher maternal age, education and household wealth and lower parity increase use, as does urban residence. Facility use in the previous delivery and antenatal care use are also highly predictive of health facility use for the index delivery, though this may be due to confounding by service availability and other factors. Obstetric complications also increase use but are rarely studied. Quality of care is judged to be essential in qualitative studies but is not easily measured in surveys, or without linking facility records with women. Distance to health facilities decreases use, but is also difficult to determine. Challenges in comparing results between studies include differences in methods, context-specificity and the substantial overlap between complex variables.
Studies of the determinants of skilled attendance concentrate on sociocultural and economic accessibility variables and neglect variables of perceived benefit/need and physical accessibility. To draw valid conclusions, it is important to consider as many influential factors as possible in any analysis of delivery service use. The increasing availability of georeferenced data provides the opportunity to link health facility data with large-scale household data, enabling researchers to explore the influences of distance and service quality.