Women at risk: Gender inequality and maternal health

Link between gender inequality and women's satisfaction with maternal healthcare services: a cross-sectional study in Khulna, Bangladesh

BACKGROUND

Gender inequality within households remains a significant barrier to accessing maternal healthcare services in many low-resource settings, including Bangladesh. Understanding the relationship between the gender inequality faced by women in households and their perceived satisfaction with maternal healthcare services is important.

OBJECTIVE

This study aims to identify the factors influencing gender inequality and investigate the association between gender inequality faced by women within households and their perceived satisfaction with maternal healthcare services.

DESIGN

Conducted between October and November 2022, employing a cross-sectional design.

SETTINGS AND PARTICIPANTS

150 women who are at their prenatal or postnatal stages are systematically sampled from Khalishpur municipality and Dighalia subdistrict from Khulna, Bangladesh.

OUTCOME MEASURES

Gender inequality within the households is assessed using a validated five-point Likert scale of five items. Participants with an average score below or equal to the median value are considered to be facing gender inequality within households. Satisfaction with maternal healthcare services is measured across five variables using a similar scale. Based on the responses, a standardised score is generated to measure the satisfaction level with maternal healthcare services.

RESULTS

We find that women are around seven times more likely to experience gender inequality in their households if their husbands are engaged in self-employed jobs or skilled labour compared with unemployment (p<0.10). Coercive actions, such as physical assault (odds: 6.428, p<0.01) and preventing women from financially supporting their maternal kin (odds: 14.909; p<0.01), are positively related to gender inequality. Such inequality negatively relates to women's perceived satisfaction with their maternal healthcare services (-1.851, p<0.01). Additionally, traditional home delivery, verbal abuse and the forced use of traditional medication reduce satisfaction levels. On the other hand, increased prenatal care is expected to increase satisfaction with maternal services as perceived by women (0.545, p<0.10).

CONCLUSIONS

The study prioritises promoting equity in opportunities for both males and females, with access to maternal health, and educational opportunities within households. Reduced inequality within households may help minimise the extent of coercive behaviour against women. The national maternal health strategy should focus on basic health services for pregnant women, with free prenatal and postnatal check-ups for pregnant mothers to improve their perinatal healthcare services.

Spatial-temporal patterns and predictors of timing and inadequate antenatal care utilization in Zambia: A Generalized Linear Mixed Model (GLMM) investigation from 1992 to 2018

Antenatal care (ANC) plays a crucial role in preventing and detecting pregnancy risks, facilitating prompt treatment, and disseminating essential information to expectant mothers. This role is particularly vital in developing countries, where a 4.65% rise in maternal mortality rate was observed in 2022, with over 800 maternal and 7,700 perinatal deaths reported. The study aimed at investigating the spatial temporal patterns and associated factors of timing and inadequacy of antenatal care utilization in Zambia, from 1992 to 2018 using a Generalized Linear Mixed Effect Model (GLMM) approach. The study utilized the Zambia Demographic Health Survey (ZDHS) database. The relationship between dependent and independent variables was examined using the Rao-Scott Chi-square test. Predictors of inadequate utilisation of ANC were identified through the multilevel generalised linear model. Spatial effects were modeled using Quantum Geographic Information System (QGIS) version 3.34.1 to develop univariate choropleth maps. A total of 45, 140 (31, 482 women had less than 8 ANC visits and 2, 004 had 8 or more ANC visits) women with a prior childbirth were included in the study. The findings in the study revealed that among women aged 15 to 19 years in 1992, 1996 and 2013/14, the rates of inadequate antenatal care utilization (less than eight ANC visits) was 90.87%, 90.99%, and 99.63%, respectively. Lack of formal education was associated with inadequate ANC from 1992 to 2018, with percentages ranging from 91.12% to 99.64%. They were notable geospatial variations in the distribution of ANC underutilization across provinces with Luapula, Muchinga, Northwestern, Northern and Eastern recording higher proportions. Furthermore, the study showed that higher education (AOR, 0.30; 95% Confidence Interval, CI, 0.14-0.63; p = 0.001), and wealth index (AOR, 0.34; 95% CI, 0.17-0.70; p = 0.003) correlated with reduced odds of inadequate ANC utilization. In conclusion, this study highlights worrisome trends in ANC utilization in Zambia, with a significant rise in inadequacy, especially in adhering to the WHO's recommended eight ANC visits. Over the period from 1996 to 2018, there was a discernible decline in the prevalence of delayed initiation of ANC. The findings underscore a notable disparity between current ANC practices and established guidelines. Additionally, various factors predicting suboptimal ANC attendance have been identified. These insights call for targeted interventions to address the identified challenges and improve the overall quality and accessibility of ANC services in Zambia.

Matters of Gender and Social Disparities Regarding Postnatal Care Use Among Nepalese Women: A Cross-Sectional Study in Morang District

Objective

The study compares the uses of postnatal care (PNC) and women's autonomy gradients across social caste and used intersectionality concepts to estimate odds ratio of women's autonomy and social caste on complete PNC.

Methods

A community-based cross-sectional study among 600 women aged 15-49 years who had at least one child younger than the age of 2 years in Morang District, Nepal, was conducted from April to July 2019. PNC, women's autonomy (decision-making power, freedom of movement, and control over finances) and social caste were collected by both methods. Multivariable logistic regressions were used to determine associations between women's autonomy, social caste, and complete PNC.

Results

Complete PNC totaled 13.5% of respondents. About one-fourth of respondents reported poor overall autonomy; however, non-Dalit demonstrated higher autonomy than Dalit. Non-Dalit exhibited greater odds of complete PNC by four times. Women exhibited high women's autonomy in decision-making power, control over finance, and freedom of movement and have greater odds of complete PNC than low autonomy by 17, 3, and 7 times, respectively.

Conclusion

The study raises awareness of intersectionality (gender and social caste), relating to maternal health in caste-based system countries. To improve maternal health outcomes, health care personnel should identify and systematically address barriers that women of lower-caste membership face and offer these women appropriate advice or resources to obtain care. A multilevel change program that involves different actors like husbands and community leaders is needed for improving women's autonomy and lessening stigmatized perceptions, attitudes, or practices toward non-Dalit caste-members.

Achieving MDG of reducing maternal mortality ratio: A comparative study of selected South Asian countries

Reducing the maternal mortality ratio (MMR) by three quarters by 2015 was one of the major Millennium Development Goals (MDGs). I performed a comparative study of policy tools and outcomes for reducing the MMR in five major South Asian Countries-Bangladesh, India, Nepal, Pakistan, and Sri Lanka. I observed that countries with a greater focus on achieving gender parity and equal health access and having specific healthcare policies to promote maternal care were more successful in achieving the MDG of reducing the MMR. Thus, any healthcare policy targeting women should also consider gender parity and women empowerment policies of a country.

Accelerating UN Sustainable Development Goals with AI-Driven Technologies: A Systematic Literature Review of Women's Healthcare

In this paper, we critically examine if the contributions of artificial intelligence (AI) in healthcare adequately represent the realm of women's healthcare. This would be relevant for achieving and accelerating the gender equality and health sustainability goals (SDGs) defined by the United Nations. Following a systematic literature review (SLR), we examine if AI applications in health and biomedicine adequately represent women's health in the larger scheme of healthcare provision. Our findings are divided into clusters based on thematic markers for women's health that are commensurate with the hypotheses that AI-driven technologies in women's health still remain underrepresented, but that emphasis on its future deployment can increase efficiency in informed health choices and be particularly accessible to women in small or underrepresented communities. Contemporaneously, these findings can assist and influence the shape of governmental policies, accessibility, and the regulatory environment in achieving the SDGs. On a larger scale, in the near future, we will extend the extant literature on applications of AI-driven technologies in health SDGs and set the agenda for future research.

Uptake of antepartum care services in a matrilineal-matrilocal society: a study of Garo indigenous women in Bangladesh

BACKGROUND

The indigenous Garo is a close-knit matrilineal-matrilocal community. This community's expectant mothers receive less antepartum biomedical care, making them prone to maternal mortality. This study developed a conceptual framework to explore how the external environment, personal predispositions, enabling components and perceived antepartum care needs influence and generate a gap in antepartum biomedical care uptake.

METHODS

The author used qualitative data from the study area. The data were collected through conducting 24 semi-structured interviews with purposively selected Garo women. After transcribing the data, the author generated the themes, grouped them into two broader domains, and analyzed them using the grounded theory approach.

RESULTS

The emergent themes suggest adding the external environment (i.e., healthcare facilities' availability and services and culturally relevant healthcare services) to Anderson's behavioral model to understand indigenous women's antepartum care uptake disparity. Antepartum care uptake disparities arise when Andersen's behavioral model's other three drivers-personal predisposition, enabling components, and needs components-interact with the external environment. The interplay between enabling resources and the external environment is the conduit by which their predispositions and perceived needs are shaped and, thus, generate a disparity in antepartum care uptake. The data demonstrate that enabling resources include gendered power dynamics in families, home composition and income, men's spousal role, community practices of maternal health, and mother groups' and husbands' knowledge. Birth order, past treatment, late pregnancy, and healthcare knowledge are predispositions. According to data, social support, home-based care, mental health well-being, cultural norms and rituals, doctors' friendliness, affordable care, and transportation costs are perceived needs.

CONCLUSIONS

Garo family members (mothers/in-laws and male husbands) should be included in health intervention initiatives to address the problem with effective health education, highlighting the advantages of biomedical antepartum care. Health policymakers should ensure the availability of nearby and culturally appropriate pregnancy care services.

Gender equality related to gender differences in life expectancy across the globe gender equality and life expectancy

Life expectancy (LE) depends on the wider determinants of health, many of which have gendered effects worldwide. Therefore, this study aimed to investigate whether gender equality was associated with LE for women and men and the gender gap in LE across the globe. Gender equality in 156 countries was estimated using a modified global gender gap index (mGGGI), based on the index developed by the World Economic Forum between 2010 and 2021. Linear regression was used to investigate the association between the mGGGI and its economic, political, and education subindices and the gender gap in LE and women and men's LE. Overall, the mGGGI increased from 58% in 2010 to 62% in 2021. Globally, changes in the mGGGI and its economic and political subindexes were not associated with changes in the gender gap in LE or with LE for women and men between 2010 and 2020. Improvements in gender equality in education were associated with a longer LE for women and men and widening of the gender gap in LE. In 2021, each 10% increase in the mGGGI was associated with a 4.3-month increase in women's LE and a 3.5-month increase in men's LE, and thus with an 8-month wider gender gap. However, the direction and magnitude of these associations varied between regions. Each 10% increase in the mGGGI was associated with a 6-month narrower gender gap in high-income countries, and a 13- and 16-month wider gender gap in South and Southeast Asia and Oceania, and in Sub-Saharan Africa, respectively. Globally, greater gender equality is associated with longer LE for both women and men and a widening of the gender gap in LE. The variation in this association across world regions suggests that gender equality may change as countries progress towards socioeconomic development and gender equality.

Association of Higher Educational Attainment on Antenatal Care Utilization Among Pregnant Women in East Africa Using Demographic and Health Surveys (DHS) from 2010 to 2018: A Multilevel Analysis

Introduction

The use of antenatal care (ANC) plays a major role in minimizing maternal and child mortality through effective and appropriate screening, preventive, or treatment intervention. Even though almost all pregnancy-related mortalities are largely preventable through adequate use of ANC, sub-Saharan Africa (SSA), particularly East African Countries, continues to share the largest share of global maternal, and newborn mortality. Therefore, this study assesses if educational attainment is associated with optimal ANC utilization in East Africa.

Methods

A secondary data analysis was done based on Demographic and Health Surveys (DHS) from 2010 to 2018 in the 11 East African Countries. A total weighted sample of 84,660 women who gave birth in the 5 years preceding each country’s DHS survey and had ANC visits were included in this study. Data processing and analysis were performed using STATA 15 software. A multilevel mixed-effect logistic regression model was fitted to examine the association of educational attainment and ANC utilization. Variables with a p-value <0.05 were declared as significant factors associated with ANC utilization. Model comparison was done based on Akaike and Bayesian Information Criteria (AIC and BIC).

Results

The magnitude of optimal ANC utilization in East African Countries was 56.37% with 95% CI (56.03, 56.69) with the highest optimal ANC utilization in Zimbabwe (80.96%) and the lowest optimal ANC utilization in Rwanda (44.31%). Women who had higher education levels were more likely to have optimal ANC utilization, compared to those with no education (AOR = 2.34; 95 and CI; 2.11–2.59). Women who had media exposure were more likely to have optimal ANC utilization than those who have no media exposure (AOR = 1.07; 95% CI; 1.03, 1.10).

Conclusion

Antenatal care utilization was low in East African countries. Educational attainment, maternal age, wealth index, birth order, media exposure, and living countries were factors associated with ANC utilization. Efforts to improve antenatal care and other maternal health service utilization in East Africa must take into account these factors. Specifically, working on the access to mass media by women may also improve antenatal care utilization.

Does gender inequality matter for access to and utilization of maternal healthcare services in Bangladesh?

There is a high prevalence of gender gap in Bangladesh which might affect women’s likelihood to receive maternal healthcare services. In this backdrop, we aim to investigate how gender inequality measured by intrahousehold bargaining power (or autonomy) of women and their attitudes towards intimate partner violence (IPV) affects accessing and utilizing maternal health care services. We used Bangladesh Demographic and Health Survey (BDHS) data of 2014 covering 5460 women who gave birth at least one child in the last three years preceding the survey. We performed logistic regression to estimate the effect of women’s autonomy and their attitude towards IPV on access to and utilization of maternal healthcare services. Besides, we employed different channels to understand the heterogeneous effect of gender inequality on access to maternal healthcare services. We observed that women having autonomy positively influenced attaining five required antenatal care (ANC) services (AOR: 1.17; 95% CI: 0.98–1.41) and women’s negative attitudes towards IPV were positively associated with five ANC services (AOR: 1.42; 95% CI: 1.02–1.97), sufficient ANC visits (COR: 1.55; CI: 1.19–2.01), skilled birth attendant (SBA) (AOR: 1.43; 95% CI: 1.05–1.94) and postnatal care (PNC) services (AOR: 1.44; 95% CI: 1.12–1.84). Besides, rural residency, religion, household wealth, education of both women and husband were found to have some of the important channels which were making stronger effect of gender inequality on access to maternal healthcare services. The findings of our study indicate a significant association between access to maternal healthcare services and women’s autonomy as well as attitude towards IPV in Bangladesh. We, therefore, recommend to protect women from violence at home and mprove their intrahousehold bargaining power to increase their access to and utilization of required maternal healthcare services.

Influence of women's empowerment indices on the utilization of skilled maternity care: evidence from rural Nigeria

There is increasing evidence that women with the ability to exercise control over their sexual and reproductive lives have greater access to prompt prevention and treatment of maternal health disorders, resulting in a concomitant reduction in maternal morbidity and mortality. This study assessed the association between indices of women's empowerment and utilization of skilled antenatal, intrapartum and postnatal maternity care in two rural Local Government Areas in Edo State, Nigeria. Data were taken from a household survey conducted in July and August 2017, and the study sample comprised 1245 ever-married women currently in a union who had given birth in the 5 years preceding the survey. A Gender Roles Framework guided the selection of independent women's empowerment variables. Using hierarchical logistic regression, the likelihood of receiving all three levels of skilled maternal health care service (antenatal, intrapartum and postnatal) by women's empowerment variables, grouped into resource, decision-making and influencer domains following the model of Anderson and Neuman, was assessed. Of the resource domain variables, respondent's education and respondent's participation in payment for their own health care positively predicted their use of all three levels of skilled maternal care, whereas their ownership of land negatively predicted this. Two decision-making domain variables were significantly associated with respondent's use of all three levels of service: those who made decisions alone about major household purchases were twice as likely to use all three levels of services than when decisions were made by their partners or others, while respondent making decisions alone about what food to cook each day was a negative predictor. Of the influencer variables, religion and a large spousal education gap were strong positive factors, whereas living in a consensual union rather than being legally married was a negative factor. Although health system factors are important, interventions geared towards changing gender norms that constrain women's empowerment are critical to achieving maternal health-related development goals in Nigeria. A composite strategy that targets all women's empowerment indices is recommended, as Nigeria strives towards achieving SDG-3.

The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017

Background

Women in low and middle-income countries (LMICs) do not have equal access to resources, such as education, employment, or healthcare compared to men. We sought to explore health disparities and associations between gender prioritization, sociocultural factors, and household decision-making in Central Malawi.

Methods

From June–August 2017, a cross-sectional study with 200 participants was conducted in Central Malawi. We evaluated respondents’ access to care, prioritization within households, decision-making power, and gender equity which was measured using the Gender-Equitable Men (GEM) scale. Relationships between these outcomes and sociodemographic factors were analyzed using multivariable mixed-effect logistic regression.

Results

We found that women were less likely than men to secure community-sourced healthcare financial aid (68.6% vs. 88.8%, p < 0.001) and more likely to underutilize necessary healthcare (37.2% vs. 22.4%, p = 0.02). Both men and women revealed low GEM scores, indicating adherence to traditional gender norms, though women were significantly less equitable (W:16.77 vs. M:17.65, p = 0.03). Being a woman (Odds Ratio (OR) 0.41, 95% confidence interval (CI) 0.21–0.78) and prioritizing a woman as a decision-maker for large purchases (OR 0.38, CI 0.15–0.93) were independently associated with a lower likelihood of prioritizing women for medical treatment and being a member of the Chewa tribal group (OR 3.87, CI 1.83–8.18) and prioritizing women for education (OR 4.13, CI 2.13–8.01) was associated with a higher odds.

Conclusion

Women report greater barriers to healthcare and adhere to more traditional gender roles than men in this Central Malawian population. Women contribute to their own gender’s barriers to care and economic empowerment alone is not enough to correct for these socially constructed roles. We found that education and matriarchal societies may protect against gender disparities. Overall, internal and external gender discrimination contribute to a woman’s disproportionate lack of access to care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-020-00497-w.

Socio-demographic predictors of gender inequality among heterosexual couples expecting a child in south-central Uganda

BACKGROUND

Gender inequality is a pervasive problem in sub-Saharan Africa, and has negative effects on health and development.

OBJECTIVE

Here, we sought to identify socioeconomic predictors of gender inequality (measured by low decision-making power and high acceptance of intimate partner violence) within heterosexual couples expecting a child in south-central Uganda.

METHOD

We used data from a two-arm cluster randomized controlled HIV self-testing intervention trial conducted in three antenatal clinics in south-central Uganda among 1,618 enrolled women and 1,198 male partners. Analysis included Cochran Mantel-Haenzel, proportional odds models, logistic regression, and generalized linear mixed model framework to account for site-level clustering.

RESULTS

Overall, we found that 31.1% of men had high acceptance of IPV, and 15.9% of women had low decision-making power. We found religion, education, HIV status, age, and marital status to significantly predict gender equality. Specifically, we observed lower gender equality among Catholics, those with lower education, those who were married, HIV positive women, and older women.

CONCLUSION

By better understanding the prevalence and predictors of gender inequality, this knowledge will allow us to better target interventions (increasing education, reducing HIV prevalence in women, targeting interventions different religions and married couples) to decrease inequalities and improve health care delivery to underserved populations in Uganda.

Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND

Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.

METHODS

Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.

RESULTS

The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.

CONCLUSIONS

Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Gender inequity as a barrier to women's access to skilled pregnancy care in rural Nigeria: a qualitative study

BACKGROUND

Maternal mortality has been an issue of global importance, with continued efforts by the international development community towards its reduction. The provision of high quality maternal healthcare has been identified as a key strategy in preventing maternal mortality. Gendered intrahousehold power structures, gendered dynamics of resource allocation and women's limited ability in decision-making can have a huge impact on maternal health-seeking behaviour and overall health status. Using a gender lens, this study explores the root causes of women's limited access to and utilisation of maternal healthcare services in rural areas of Edo State, Nigeria.

METHODS

This qualitative study involved the analysis of data collected from gender- and age-desegregated focus group discussions (FDGs) in 20 communities in Etsako East and Esan South East local government areas of Edo State, Nigeria. Focus group participants comprised women between the ages of 15-45 y who have been pregnant within the last 5 y and their male spouses and partners of varying ages. A total of 20 FGDs were conducted. Coded transcripts were reviewed and analysed using the gender framework as an analytical guide.

RESULTS

Most responses indicated that women did not entirely have the power to make decisions regarding when to seek care during pregnancy. Women's experiences of access to quality care showed intersecting areas of gender and social economic status (SES) and how they impact on access to health. Many of the responses suggested high levels of economic marginalisation among women with women being financially dependent on their spouses and partners for pregnancy healthcare-related costs. Furthermore, a man's financial status determined the type of care his spouse or partner sought. Women identified a high workload as an issue during pregnancy and a barrier to accessing maternal healthcare services. The role of men within households was generally perceived as that of financial providers, therefore a husband's support was commonly constructed to solely mean financial support.

CONCLUSION

This paper brings attention to the role of gender and SES in producing and sustaining limitations to women's access to quality care. Interventions geared towards supporting women's financial independence is an important step towards improving their access to skilled healthcare, more so are interventions that improve women's decision-making capacities.

Gender inequality and sexual height dimorphism in Chile

Chile has experienced significant improvements in its economy; thus, a secular trend in height has been observed in its population. Gender equality has also improved hand in hand with active policies addressing the gender gap in several dimensions (work, education, health) and overall economic improvement. This study examined changes in sexual height dimorphism in four samples of Chilean male and female working-age subjects and attempted to establish associations with gender equality and welfare. Sexual height dimorphism was calculated and compared with gender equality and overall welfare indicators between 1955 and 1995. Sexual height dimorphism reduction was seen to be strongly associated with greater gender equality and some general welfare indicators, such as the infant mortality rate. Gross domestic product per capita was not associated with sexual height dimorphism, but it showed significant associations with gender equality indicators. Overall, the gender gap has been reduced in Chile, which can be observed through improvements in gender equality indicators and a reduction in height dimorphism, mainly in areas associated with women's health. However, gender equality is still far behind in terms of female labour participation and women in political power, which require attention and further improvements.

Deliver on Your Own: Disrespectful Maternity Care in rural Kenya

BACKGROUND

Under the Free Maternity Policy (FMP), Kenya has witnessed an increase in health facility deliveries rather than home deliveries with Traditional Birth Attendants (TBA) resulting in improved maternal and neonatal outcomes. Despite these gains, maternal and infant mortality and morbidity rates in Kenya remain unacceptably high indicating that more needs to be done.

AIM

Using data from the Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project's qualitative gender assessment, this paper examines women's experience of disrespectful care during pregnancy, labour, and delivery. The goal is to promote an improved understanding of the actual care conditions to inform the development of interventions that can lift the standard of care, increase maternity facility use, and improve health outcomes for both women and newborns.

METHODOLOGY

We conducted sixteen focus group discussions (FGDs), two each for adolescent females, adult females, adult males, and community health committee members. As well, twenty-four key Informants interviews (KII) were also conducted including religious leaders, and persons from local government representatives, Ministry of Health (MOH), and local women's organizations. Data were captured through audio recordings and reflective field notes.

RESEARCH SITE

Kisii and Kilifi Counties in Kenya.

FINDINGS

Findings show nursing and medical care during labour and delivery were at times disrespectful, humiliating, uncompassionate, neglectful, or abusive. In both counties, male health workers were preferred by women giving birth, as they were perceived as more friendly and sensitive. Adolescent females were more likely to report abuse during maternity care while women with disabled children reported being stigmatized. Structural barriers related to transportation and available resources at facilities associated with disrespectful care were identified.

CONCLUSIONS

A focus on quality and compassionate care as well as more facility resources will lead to increased, successful, and sustainable use of facility care. Interpreting these results within a systems perspective, Kenya needs to implement, enforce, and monitor quality of care guidelines for pregnancy and delivery including respectful maternity care of pregnant women. To ensure these procedures are enforced, measurable benchmarks for maternity care need to be established, and hospitals need to be regularly monitored to ensure these benchmarks are achieved.

Social and Demographic Predictors of Gender Inequality Among Heterosexual Couples Expecting a Child in Central Kenya

Imbalance of power and equality in sexual relationships is linked to health in various ways, including (1) reduced ability to get information or take action, (2) increased violence between partners, and (3) influence on the reduced use of health services. While there has been research assessing multiple social and economic variables related to gender inequality, studies have used many different definitions of gender inequality, and there is a lack of this research within a pregnancy context. Here, we attempt to identify social and economic predictors of gender inequality (measured by decision-making power and acceptance of intimate partner violence) within heterosexual couples expecting a child in central Kenya. We ran a secondary data analysis using data from a three-arm individually randomized controlled HIV self-testing intervention trial conducted in 14 antenatal clinics in central and eastern Kenya among 1410 women and their male partners. The analysis included Cochran Mantel-Haenszel, logistic regression, proportional odds models, and generalized linear mixed model (GLMM) framework to account for site-level clustering. Overall, we show that there are significant social and economic variables associated with acceptance of intimate partner violence including higher age, being married, "other" religion, lower partner education, higher wealth status, and variables associated with decision-making power including lower partner education and lack of equality in earnings. This study contributes to the literature on the influence of social and economic factors on gender inequality, especially in Kenya which has a high burden of HIV/AIDS. Our results show some areas to improve these specific factors (including education and employment opportunities) or create interventions for targeted populations to potentially improve gender equality in heterosexual pregnant couples in Kenya.

Bride price payment and women's autonomy: Findings from qualitative interviews from Nigeria

Marriage involving a man and a woman is a universal social institution, but its practices vary among cultures. In Nigeria, a marriage is recognized after gifts are given, and a bride price is paid by the groom's family to the bride's family. Understanding the bride price will reduce the challenges women face in their marital homes. Women's autonomy is important for them to address matters affecting their health. We examined married Ikwerre women's perspectives on bride price and its impact on their autonomy using qualitative methods. From December 2014 to March 2015, 34 in-depth interviews and six focus group discussions were conducted with married Ikwerre women. Participants reported that patriarchy and a culture of absolute respect for men, not the bride price, was the reason for women's diminished autonomy. Participants noted that payment of the bride price was critical for validating marriage to give women respectable status in society as wives. Patriarchal rule and the demand for absolute respect for men need to be addressed in the Ikwerre culture. A woman's capability to address her health needs and use health care is largely dependent on her ability to act autonomously. Thus, educational interventions to enable women's decision-making are critical.

Predictors of women's utilization of primary health care for skilled pregnancy care in rural Nigeria

BACKGROUND

Although Primary Health Care (PHC) was designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths, very little is known of the factors that predict the use of PHC for skilled maternity care in rural parts of Nigeria - where its use is likely to have a greater positive impact on maternal health care. The objective of this study was to identify the factors that lead pregnant women to use or not use existing primary health care facilities for antenatal and delivery care.

METHODS

The study was a cross-sectional community-based study conducted in Esan South East and Etsako East LGAs of Edo State, Nigeria. A total of 1408 randomly selected women of reproductive age were interviewed in their households using a pre-tested structured questionnaire. The data were analyzed with descriptive and multivariate statistical methods.

RESULTS

The results showed antenatal care attendance rate by currently pregnant women of 62.1%, and a skilled delivery of 46.6% by recently delivered women at PHCs, while 25% of women delivered at home or with traditional birth attendants. Reasons for use and non-use of PHCs for antenatal and delivery care given by women were related to perceptions about long distances to PHCs, high costs of services and poor quality of PHC service delivery. Chi-square test of association revealed that level of education and marital status were significantly related to use of PHCs for antenatal care. The results of logistic regression for delivery care showed that women with primary (OR 3.10, CI 1.16-8.28) and secondary (OR 2.37, CI 1.19-4.71) levels education were more likely to receive delivery care in PHCs than the highly educated. Being a Muslim (OR 1.56, CI 1.00-2.42), having a partner who is employed in Estako East (OR 2.78, CI 1.04-7.44) and having more than five children in Esan South East (OR 2.00, CI 1.19-3.35) significantly increased the odds of delivery in PHCs. The likelihood of using a PHC facility was less for women who had more autonomy (OR 0.75, CI 0.57-0.99) as compared to women with higher autonomy.

CONCLUSION

We conclude that efforts devoted to addressing the limiting factors (distance, costs and quality of care) using creative and innovative approaches will increase the utilization of skilled pregnancy care in PHCs and reduce maternal mortality in rural Nigeria.