EXAMINING INTER-GENERATIONAL DIFFERENTIALS IN MATERNAL HEALTH CARE SERVICE UTILIZATION: INSIGHTS FROM THE INDIAN DEMOGRAPHIC AND HEALTH SURVEY

Ninety-one years of midwifery continuity of care in low and middle-income countries: a scoping review

BACKGROUND

Midwifery continuity of care during pregnancy, childbirth, and postpartum is essential for improving maternal and neonatal health outcomes. In low- and middle-income countries (LMICs), however, challenges such as healthcare worker shortages, limited infrastructure, poor healthcare access, and cultural barriers often hinder the effective provision of midwifery services. These issues contribute to unsustainable and inadequate care, adversely affecting maternal and newborn health. This study examines the impact of these challenges on the midwifery continuity of care and its subsequent effect on maternal and neonatal outcomes.

METHODS

A scoping review was conducted following Arksey and O'Malley's framework. We analyzed 43 articles published between 1932 and 2023 across four databases. Included studies were conducted in LMICs, focused on continuous care models, and published in English. The review aimed to capture the varied impacts of midwifery care on health outcomes.

RESULTS

The review found that midwifery continuity of care in LMICs significantly improves maternal and newborn health by reducing medical interventions, increasing physiological births, and enhancing maternal satisfaction and breastfeeding rates. The approach also lowers newborn mortality and morbidity. Success factors include community acceptance, midwives' cultural competence, and collaboration with traditional birth attendants. Barriers such as insufficient funding and resistance to change persist. Midwife-led continuity of care (MLCC) was associated with a 16% reduction in neonatal loss and a 24% reduction in pre-term births. Also, MLCC decreases newborn mortality by 10-20% and increases breastfeeding rates by up to 30%. Effective implementation requires integrating midwifery services into existing health systems, securing funding, expanding training, and strengthening community partnerships.

CONCLUSIONS

Midwifery continuity of care enhances maternal and neonatal health in LMICs by minimizing unnecessary medical interventions and improving maternal satisfaction and breastfeeding outcomes. However, cultural and socioeconomic factors influence its acceptance. Further research is needed to integrate traditional birth attendants into formal health systems, overcome resistance to change, and develop strategies for effective collaboration between traditional and professional care providers.

Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India

BACKGROUND

Low birth weight (LBW) predisposes physical and mental growth failure and premature death among infants. Studies report that LBW predominately explains infant mortality. However, existing studies rarely demonstrate the phenomenon of both observed and unobserved factors, which may influence the likelihood of birth and mortality outcomes simultaneously. In this study, we identified the spatial clustering of the prevalence of LBW along with its determinants. Further, the relationship between of LBW and infant mortality, considering the unobserved factors, has been explored in the study.

METHODS

Data for this study have been extracted from the National Family Health Survey (NFHS) round 5, 2019-21. We used the directed acyclic graph model to identify the potential predictors of LBW and infant mortality. Moran's I statistics have been used to identify the high-risk areas of LBW. We applied conditional mixed process modelling in Stata software to account for the simultaneous nature of occurrences of the outcomes. The final model has been performed after imputing the missing data of LBW.

RESULTS

Overall, in India, 53% of the mothers reported their babies' birth weight by seeing health card, 36% reported by recall, and about 10% of the LBW information was observed as missing. The state/union territory of Punjab and Delhi were observed to have the highest levels of LBW (about 22%) which is much higher than the national level (18%). The effect of LBW was more than four times larger compared to the effect in the analysis which does not account for the simultaneous occurrence of LBW and infant mortality (marginal effect; from 12 to 53%). Also, in a separate analysis, the imputation technique has been used to address the missing data. Covariates' effects showed that female children, higher order births, births that occur in Muslim and non-poor families and literate mothers were negatively associated with infant mortality. However, a significant difference was observed in the impact of LBW before and after imputing the missing values.

CONCLUSIONS

The current findings showed the significant association of LBW with infant deaths, highlighting the importance of prioritising policies that help improve the birth weight of new-born children that may significantly reduce the infant mortality in India.

Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings

OBJECTIVES

The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums.

METHODS

The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066.

RESULTS

The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel.

CONCLUSION

Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets.

Dimensions of women's empowerment on access to skilled delivery services in Nepal

Background

Each day, approximately 810 women die during pregnancy and childbirth and 94% of the deaths take place in low and middle income countries. Only 45% of the births in South Asia are attended by skilled professionals, which is lower than that in other Asian regions. Antenatal and postnatal care received from skilled providers can help prevent maternal and neonatal mortality by identifying pregnancy-related complications. Women’s empowerment is considered to be a significant determinant of maternal health care outcomes; however, studies on the contextual influences of different dimensions of empowerment in Nepal are relatively limited. Therefore, this study analyzed nationwide survey data to examine the influence of women’s economic empowerment, sociocultural empowerment, familial/interpersonal empowerment and media and information technology empowerment on accessing skilled delivery services among the married women in Nepal.

Methods

This study examined the influence of women’s empowerment on skilled delivery services among married women (n = 4400) aged 15–49 years using data from the 2016 Nepal Demographic and Health Survey. Descriptive analysis and binary logistic regression analysis were employed to analyze the data.

Results

Significant associations were found between women’s media and information technology empowerment, economic empowerment and sociocultural empowerment and access to skilled birth attendants. Specifically, the education of women, their occupation, owning a bank account, media exposure, and internet use were significantly associated with the use of skilled birth attendants.

Conclusion

Focusing on women’s access to media and information technology, economic enhancement and education may increase the use of skilled birth attendants in Nepal.

Improving use of maternal care services among married adolescent girls: an intervention study in rural India

This study examined the effect of the Safe Adolescent Transition and Health Initiative (SATHI) programme on the use of maternal care services among rural, pregnant adolescents in India. This was an intensive community-based, multi-site intervention project conducted in Maharashtra state between 2008 and 2011. Its aims were to improve the reproductive health of married adolescent girls and avert the adverse consequences of early motherhood. It had a quasi-experimental, case-control, pre-post design to enable rigorous evaluation. This study used cross-sectional data from 644 married girls aged under 19 years at baseline and 802 at endline to assess the maternal care outcomes of antenatal care, delivery and postnatal services and nutrition during pregnancy. Difference-in-differences analysis showed that all outcomes improved significantly in the study sites between baseline and endline, and the improvement in study sites was significantly larger than in the control sites. Multivariate analysis showed a statistically significant dose-response effect of intervention participation for antenatal care, pregnancy nutrition and postnatal care. Study participation was not statistically significantly associated with higher rates of safe or institutional delivery. The analysis suggests that training and supporting community health workers to work with married adolescent girls using interpersonal communication and interacting frequently with them and their families and communities can significantly improve the use of maternal care services among this population. With almost a million community health workers and 200,000 auxiliary nurse midwives at the community level providing primary level care in India, this intervention offers a proven strategy to replicate and scale-up to reach large numbers of married adolescent girls who do not currently use maternal care services.

Women's empowerment and the use of antenatal care services: analysis of demographic health surveys in five Southeast Asian countries

Women's empowerment and use of antenatal care (ANC) services remain important in the Association of Southeast Asian Nations (ASEAN). This assessed the association between women's empowerment and ANC use in five ASEAN countries. ANC information for the most recent births of 29,444 currently married women in the last 5 years preceding the Demographic Health Survey was analyzed (Cambodia [DHS2014], Indonesia [DHS2012], Myanmar [DHS2015-2016], Philippines [DHS2013], and Timor-Leste [DHS2009]). Analyses used multiple logistic regression adjusting for complex sampling designs. The number of ANC visits was positively associated with labor-force participation in Cambodia, the Philippines, and Timor-Leste; with disagreement with justification for wife beating and women's knowledge level in Cambodia, Indonesia, Myanmar; and with women's decision-making power in Cambodia and Indonesia. The association of women's empowerment variables with timing of the first ANC visit was not as evident as that for number of ANC visits. Compared to adult mothers, adolescent mothers with medium knowledge level had less odds of attending ≥4 ANC in Cambodia, and adolescent mothers with the poorest labor-force participation had lower odds of attending the first ANC early in Myanmar. Tailored policy on women's improved access to labor force and health information in each country may be needed to improve ANC use.

The role of women's empowerment and male engagement in pregnancy healthcare seeking behaviors in western Kenya

We sought to understand whether women's empowerment and male partner engagement were associated with use of antenatal care (ANC). Women presenting for ANC in Nyanza province of Kenya between June 2015 and May 2016, were approached for participation. A total of 137 pregnant women and 96 male partners completed baseline assessments. Women's empowerment was measured using the modified Sexual Relationship Power Scale. ANC use measures included timing of the first ANC visit and number of visits. Male engagement was based on whether a husband reported accompanying his wife to one or more antenatal visits during the pregnancy. Multiple linear and logistic regression analyses were used to identify factors independently related to use and timing of ANC. Women with higher mean empowerment scores were likely to have more than one ANC visit in the index pregnancy [Adjusted Odds Ratio (AOR) = 2.8, 95% Confidence Interval (CI): 1.1-7.3], but empowerment was not associated with early ANC use. Women who were more empowered were less likely to have a husband who reported attending an ANC visit with his wife (AOR = 0.1, 95% CI: 0.03-0.8). Women's empowerment is important and may be related to ANC use and engagement of male partners in complex ways.

Associations between quantitative measures of women's empowerment and access to care and health status for mothers and their children: A systematic review of evidence from the developing world

Research on the association between women's empowerment and maternal and child health has rapidly expanded. However, questions concerning the measurement and aggregation of quantitative indicators of women's empowerment and their associations with measures of maternal and child health status and healthcare utilization remain unanswered. Major challenges include complexity in measuring progress in several dimensions and the situational, context dependent nature of the empowerment process as it relates to improvements in maternal and child health status and maternal care seeking behaviors. This systematic literature review summarizes recent evidence from the developing world regarding the role women's empowerment plays as a social determinant of maternal and child health outcomes. A search of quantitative evidence previously reported in the economic, socio-demographic and public health literature finds 67 eligible studies that report on direct indicators of women's empowerment and their association with indicators capturing maternal and child health outcomes. Statistically significant associations were found between women's empowerment and maternal and child health outcomes such as antenatal care, skilled attendance at birth, contraceptive use, child mortality, full vaccination, nutritional status and exposure to violence. Although associations differ in magnitude and direction, the studies reviewed generally support the hypothesis that women's empowerment is significantly and positively associated with maternal and child health outcomes. While major challenges remain regarding comparability between studies and lack of direct indicators in key dimensions of empowerment, these results suggest that policy makers and practitioners must consider women's empowerment as a viable strategy to improve maternal and child health, but also as a merit in itself. Recommendations include collection of indicators on psychological, legal and political dimensions of women's empowerment and development of a comprehensive conceptual framework that can guide research and policy making.

Magnitude and trends of inequalities in antenatal care and delivery under skilled care among different socio-demographic groups in Ghana from 1988 - 2008

Background

Improving maternal and reproductive health still remains a major challenge in most low-income countries especially in sub-Saharan Africa. The growing inequality in access to maternal health interventions is an issue of great concern. In Ghana, inadequate attention has been given to the inequality gap that exists amongst women when accessing antenatal care during pregnancy and skilled attendance at birth. This study therefore aimed at investigating the magnitude and trends in income-, education-, residence-, and parity-related inequalities in access to antenatal care and skilled attendance at birth.

Methods

A database was constructed using data from the Ghana Demographic and Health Surveys (DHS) 1988, 1993, 1998, 2003, and 2008. The surveys employed standard DHS questionnaires and techniques for data collection. We applied regression-based Total Attributable Fraction (TAF) as an index for measuring socioeconomic inequalities in antenatal care and skilled birth attendance utilization.

Results

The rural–urban gap and education-related inequalities in the utilization of antenatal care and skilled birth attendants seem to be closing over time, while income- and parity-related inequalities in the use of antenatal care are on a sharp rise. Income inequality regarding the utilization of skilled birth attendance was rather low and stable from 1988 to 1998, increased sharply to a peak between 1998 and 2003, and then leveled-off after 2003.

Conclusions

The increased income-related inequalities seen in the use of antenatal care and skilled birth attendance should be addressed through appropriate strategies. Intensifying community-based health education through media and door-to-door campaigns could further reduce the mentioned education- and parity-related inequalities. Women should be highly motivated and incentivized to attend school up to secondary level or higher. Education on the use of maternal health services should be integrated into basic schools so that women at the lowest level would be inoculated with the appropriate health messages.