Women's progression through the maternal continuum of care in Guinea: Evidence from the 2018 Guinean Demographic and Health Survey

Wealth-based inequality and dropout rate in the completion of the continuum of maternal healthcare in Ethiopia: a secondary data analysis of the Mini Demographic and Health Survey of 2019

OBJECTIVE

To determine wealth-based inequality and the dropout rate in the completion of the maternal continuum of care (CoC) in Ethiopia.

SETTING

Ethiopian Demographic and Health Survey-2019.

PARTICIPANTS

Reproductive-age women (15-49 years) in Ethiopia.

PRIMARY OUTCOME

Completion of the maternal CoC services is the primary outcome. Maternal CoC is defined as a situation where women have at least four antenatal care (ANC) visits, deliver their babies at a health facility and receive at least one postnatal care service for both mother and newborn baby.

METHODS

We analysed the 2019 Mini demographic and health survey data using STATA V.17. Multilevel logistic regression analysis was employed for the factors associated with the maternal CoC. The concentration index was used to measure equity.

RESULT

Overall, 24% (95% CI: 21.6 to 26.5) of women completed the maternal CoC. There was wealth-based inequality in the completion of maternal CoC in Ethiopia (concentration index: 0.25 (95% CI: 0.18 to 0.31, p≤0.001)), rural residents (concentration index: 0.15 (95% CI: 0.09 to 0.21, p≤0.001)) and urban residents (concentration index: 0.15 (95% CI: 0.05 to 0.26, p≤0.01)). Being an urban resident (adjusted OR (AOR)=1.59, 95% CI: 1.09 to 2.33), attaining secondary (AOR=1.67, 95% CI: 1.19 to 2.33) or higher education (AOR=1.93, 95% CI: 1.30 to 2.87) and early initiation of ANC (AOR=1.97, 95% CI: 1.61 to 2.41) were positively associated with the completion of maternal CoC. However, belonging to a pastoral region (Afar or Somali) (AOR=0.46, 95% CI: 0.28 to 0.77), belonging to the poorest (AOR=0.58, 95% CI: 0.37 to 0.92) or middle (AOR=0.62, 95% CI: 0.40 to 0.96) wealth quintile, not being informed about obstetric danger signs (AOR=0.54, 95% CI: 0.43 to 0.66) and blood pressure not being measured (AOR=0.53, 95% CI: 0.32 to 0.85) were negatively associated with maternal CoC.

CONCLUSION

We concluded that completion of the maternal CoC was low in Ethiopia. There was significant inequality in the completion of maternal CoC across wealth status, place of residence and educational status. Strategies and interventions that target the disadvantaged group of women are needed to improve the utilisation of maternal healthcare services. Tailored and multisectoral intervention considering women with poor or middle wealth, women in pastoralist regions and women with no information on obstetric danger signs improves the CoC practice in the country.

Trends and contributors of complete continuum of maternal healthcare service utilization in Ethiopia: a multivariate decomposition analyses

BACKGROUND

Most maternal deaths are preventable by accessing essential maternity healthcare services. However, maternal mortality rates remain high in Ethiopia partly due to only a few women using a complete Continuum of Maternal Healthcare Services (CMHS). This study aims to assess trends and contributors for complete CMHS utilization in Ethiopia.

METHODS

Ethiopian Demography and Health Survey (EDHS) 2011-2019 data were used to assess the trends of complete CMHS utilization. A total weighted sample of 10,768 women (3333 in 2011, 4590 in 2016, and 2845 in 2019) were included in the analysis. A logit-based multivariate decomposition analysis was undertaken to assess the change in the proportion of complete CMHS utilization and its contributors between 2011 and 2019.

RESULTS

In Ethiopia, trends of complete CMHS utilization among women increased from 9.6% (95% CI 8.4, 10.9) in 2011 to 29.9% (95% CI 27.3, 32.6) in 2019. In the decomposition analysis, 60.6% of the difference in the proportion of complete CMHS utilization was explained by the differences in the composition of women's characteristics, and 39.4% was attributed to coefficients of characteristics. As such, equalizing the number of women who attended school at secondary level or higher, had television, initiated antenatal care (ANC) visits in the first trimester, were aware of pregnancy-related complications, delivered by caesarean section for their most recent childbirth, were from poorer households, gave urine and blood samples during pregnancy in 2019-2011 levels, would reduce the differences between 2011 to 2019 in complete CMHS utilization. In contrast, equalizing the number of women from richer (higher) household wealth categories in 2019-2011 levels would increase the 2011-2019 gaps in complete CMHS utilization.

CONCLUSION

While progress has been made, complete CMHS utilization was low in Ethiopia. Differences in the composition of characteristics and effect of coefficients had a substantial contribution to the change in complete CMHS utilization between 2011 and 2019. Adopting a multi-faceted approach that considers the unique challenges within the country, including women's education, wealth status, and quality of care, will improve CMHS utilization. Empowering women through education can enhance their decision-making ability regarding their own health.

Frequency and factors associated with focused antenatal care in Guinea: Analysis of the DHS 2018

Background

In Guinea, despite women's recourse to antenatal care (ANC), little remains known about the use of focused antenatal care (FANC), contained in the ANC package.

Aim

The aim of this study was to analyse the frequency and factors associated with FANC, using data from the Demographic and Health Survey (DHS) 2018.

Setting

This study was conducted in Guinea.

Methods

This was a secondary analysis of data from the DHS conducted in 2018 in Guinea. It included all women who achieved at least one ANC visit in the last 2 years prior to the survey. Multivariate logistic regression was received to identify factors associated with FANC. Stata 16 software was used for the analysis.

Results

This study shows that in Guinea, between 2016 and 2018 only 33% of women undergoing ANC received a FANC. The most commonly used service was blood pressure measurement (93%), while the least commonly used service was deworming (42%). Factors associated with FANC were living in the Kindia region (odds ratio = 1.7; 95% confidence interval: 1.04-2.97); not intending to become pregnant for this pregnancy; belonging to a poor household; and having made 3, 4 or more ANC visits.

Conclusion

This study reports a low proportion of women receiving the full package of ANC.

Contribution

In order to improve this indicator, greater efforts need to be made in certain regions of the country to target pregnant women who achieve fewer ANC visits, carry pregnancies that were not intentional or belong to poorer households.

Utilisation and associated socio-demographic factors related to the maternal continuum of care in sub-Saharan Africa: A systematic review and meta-analysis

Background

Maternal continuum of care (MCC) is the utilisation of maternal health care services, including 4+ antenatal care (ANC) visits, skilled birth attendants (SBAs), and postnatal care (PNC). This systematic review and meta-analysis assessed the pooled proportion of MCC utilisation among women in sub-Saharan Africa (SSA) and its association with selected sociodemographic factors.

Methods

We identified keywords and MeSH terms related to the condition (MCC), the context (SSA), and population (women with history of childbirth) to search for published or unpublished observational studies. We used the Joanna Briggs Institute tool to extract data and the Newcastle Ottawa Scale for quality assessment. Meta-analysis was used to compute pooled estimates (MCC utilisation and odds ratio (OR) associates) with 95% confidence intervals (CI) using Stata 17.

Results

Of 45 402 studies identified, we included 23 involving 320 353 women. The pooled estimate of MCC utilisation across SSA was 18.72% (95% CI = 14.51, 22.93), showing a significant increase (P < 0.05) from 2015 to 2022. Southern Africa had the highest MCC utilisation (38%; 95% CI = 36.59, 39.41), while East Africa had the lowest (17.5%; 95% CI = 12.22, 22.75). Maternal continuum of care utilisation was associated with maternal age 25-34 years (pooled odds ratio (POR) = 1.27), urban residence (POR = 2.69), richer/richest wealth status (POR = 1.68), as well as higher level of education and employment (POR = 1.32).

Conclusions

MCC utilisation in SSA remains low, with significant variation across the sub-regions and sociodemographic strata. Context-specific interventions targeting identified factors are essential to enhance MCC utilisation in SSA.

Registration

PROSPERO: CRD42021272708.

State of the maternal healthcare continuum in Guinea, awaiting the next Demographic and Health Survey: the case of the five communes of Conakry in 2022

Background

The continuum of maternal health care ensures consistency in the delivery of care from pregnancy to the postnatal period. It recommends a minimum of 4 antenatal visits, skilled birth attendance, and 42 days of postnatal care. This approach helps reduce maternal deaths. The aim of this study was to estimate the proportion of women who had completed the different stages of the continuum of maternal health care (four antenatal visits, given birth under the care of qualified personnel, and received postnatal care within 42 days of delivery).

Methods

This was a cross-sectional analytical study conducted in the five communes of Conakry, using a two-stage cluster sampling for data collection. Results were described using medians and percentages. The proportions of women in the continuum of care, and at the different stages of this continuum, have been weighted. Multivariate logistic regression was used to identify the factors associated with non-completion of the different stages of the maternal health care continuum among the women included in this study.

Results

We found that 26.9% of women had completed all stages of the maternal health care continuum, while 73.1% had not. While 56.7% received four antenatal visits, only 29.5% delivered under the care of a qualified healthcare professional. Key factors associated with discontinuity were not attending school (AOR 1.825: 1.594-2.089), unemployment (AOR 4.588: 3.983-5.285), having two or more living children (AOR 1.890: 1.016-1.296), and not receiving a free Long-Lasting Insecticidal Net at the first Antenatal Care.

Conclusion

Maternal care discontinuity is a major issue in Guinea. The country's Health Development Plan had set an expected level for maternal care which has not been met as of 2022. The completeness of care is influenced by various factors, including individual socio-demographic characteristics and factors related to the organization, availability, and quality of health services. To reduce maternal and child mortality rates, it is essential to improve interpersonal communication during antenatal care, ensure the availability of quality health services, and conduct a national study on maternal health service quality and maternal satisfaction. This will help establish a proper continuum of care for mothers and children.

The continuum of care for maternal health in Africa: A systematic review and meta-analysis

BACKGROUND

The continuum of care for maternal health (COCM) is a critical strategy for addressing preventable causes of maternal and perinatal mortality. Despite notable progress in reducing maternal and infant deaths globally, the problem persists, particularly in low-resource settings. Additionally, significant disparities in the provision of continuous care exist both between continents and within countries on the same continent. This study aimed to assess the pooled prevalence of completion across the maternity care continuum in Africa and investigate the associated factors.

METHODS

Relevant articles were accessed through the EMBASE, CINAHL, Cochrane Library, PubMed, HINARI, and Google Scholar databases. Funnel plots and Egger's test were employed to assess publication bias, while the I-squared test was used to evaluate study heterogeneity. The inclusion criteria were limited to observational studies conducted exclusively in Africa. The quality of these studies was assessed using the JBI checklist. Data extraction from the included studies was performed using Microsoft Excel and then analysed using Stata 16 software.

RESULTS

A total of 23 studies involving 74,880 mothers met the inclusion criteria. The overall prevalence of women who successfully completed the COCM was 20.9% [95% CI: 16.9-25.0]. Our analysis revealed several factors associated with this outcome, including urban residency [OR: 2.3; 95% CI: 1.6-3.2], the highest wealth index level [OR: 2.1; 95% CI: 1.4-3.0], primiparous status [OR: 1.3; 95% CI: 2.2-5.1], planned pregnancy [OR: 3.0; 95% CI: 2.3-3.7], and exposure to mass media [OR: 2.7; 95% CI: 1.9-3.8].

CONCLUSION

The study revealed that only 20.9% of women fully completed the COCM. It also identified several factors associated with completion of the COCM, such as residing in urban areas, possessing a higher wealth index, being a first-time mother, experiencing a planned pregnancy, and having access to mass media. Based on the study's findings, it is recommended that targeted interventions be implemented in rural areas, financial assistance be provided to women with lower wealth index levels, educational campaigns be conducted through mass media, early antenatal care be promoted, and family planning services be strengthened.

REVIEW REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42020205736).

Spatial distribution and associated factors of dropout from health facility delivery after antenatal booking in Ethiopia: a multi-level analysis

BACKGROUND

Nowadays, retaining women in the continuum of care throughout the lifecycle: adolescence, pregnancy, childbirth, postpartum, and childhood in reproductive health is one of the recent global concerns. Most of the previous studies focused on individual-level factors and used classical logistic regression. Furthermore, it doesn't take into account its distribution. Therefore, this study aimed to assess spatial distribution, and associated factors of dropout from health facility delivery after antenatal booking among postpartum women in Ethiopia.

METHOD

Cross-sectional study by secondary analysis of the Ethiopian Mini Demographic and Health Survey (EMDHS) 2019 dataset was conducted among postpartum women. A total of 2882 women who gave birth 5 years prior to the survey were included. Sampling weight was applied and the analysis was done using STATA version 16. Aeronautical Reconnaissance Coverage Geographic Information System (ArcGIS) 10.8 software was used to map the cluster and attribute of dropout from health facility delivery and Global and local Moran's Index methods were used to assess the extent of clustering. Multi-level (two-level) logistic regression analysis was used and variables with a P value less than 0.5 were considered statistical significance. Adjusted odds ratio AOR) with a 95% confidence interval was used to show the strength and direction of the association respectively.

RESULTS

Dropout from health facility delivery after ANC (Antenatal Care) booking in Ethiopia was 35.42%, 95% CI (33.70, 37.19), and it spatially clustered (Moran's index = 0.51, P value < 0.001). From individual-level variables: women who were primary educated [AOR = 0.70, 95% CI (0.49, 0.98)], secondary educated [AOR = 0.38, 95% CI (0.19, 0.73)], lived in the middle [AOR = 0.54, 95% CI (0.29, 0.98)], richer wealth [AOR = 0.37, 95% CI (0.18, 0.78)], richest wealth [AOR = 0.21, 95% CI (0.06, 0.74)], being counseled about pregnancy and childbirth complications [AOR = 0.52, 95% CI (0.34, 0.80)] and women who had four and above ANC visit [AOR = 0.52, 95% CI (0.38, 0.71)] were negatively associated with dropout. Whereas, second birth order [AOR = 2.62, 95% CI (1.40, 4.89)], 3-4th birth order [AOR = 4.92, 95% CI (2.82, 8.60)], above 4th birth order [AOR = 4.77, 95% CI (2.16, 10.53))] were positively associated with dropout. From community-level variables: mothers who lived in Afar [AOR = 2.61, 95% CI (1.08, 6.32)] and Oromia [AOR = 2.63, 95% CI (1.15, 6.02)] were positively associated with dropout from health facility delivery after ANC booking.

CONCLUSIONS

Dropout from health facility delivery after ANC booking was high as the government's effort and its spatial distribution in Ethiopia was clustered. Increased educational status of the mother, having four or more ANC visits, counseled about pregnancy and childbirth complications, and higher household wealth were negatively associated and higher birth order, and living in Oromia and Afar region were positively associated with dropout in Ethiopia. Strengthening women's education, encouraging women to complete ANC visits, being counseled them on pregnancy and childbirth complications, and improving family wealth status will be the recalled intervention areas of the government.

Continuum of care for maternal health in Uganda: A national cross-sectional study

Introduction

A continuum of maternal care approach can reduce gaps and missed opportunities experienced by women and newborns. We determined the level of coverage and factors associated with the continuum of maternal care in Uganda.

Methods

We used weighted data from the Uganda Demographic and Health Survey (UDHS) 2016. We included 10,152 women aged 15 to 49 years, who had had a live birth within five years preceding the survey. Stratified two-stage cluster sampling design was used to select participants. Continuum of maternal care was considered when a woman had at least four antenatal care (ANC) visits, had delivered in a health facility and they had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression analysis to determine factors associated with completion of the continuum of maternal care using SPSS version 25.

Results

The level of coverage of complete continuum of maternal care was 10.7% (1,091) (95% CI: 10.0–11.2). About 59.9% (6,080) (95% CI: 59.0–60.8) had four or more antenatal visits while 76.6% (7,780) (95% CI: 75.8–77.5) delivered in a health facility and 22.5% (2,280) (95% CI: 21.5–23.2) attended at least one postnatal care visit within six weeks. The following factors were associated with continuum of maternal care; initiating ANC in the first trimester (AOR 1.49, 95% CI: 1.23–1.79), having secondary level of education (AOR 1.60, 95% CI: 1.15–2.22) and tertiary level of education (AOR 2.08 95% CI: 1.38–3.13) compared to no formal education, being resident in Central Uganda (AOR 1.44, 95% CI:1.11–1.89), Northern Uganda (AOR 1.35, 95% CI: 1.06–1.71) and Western Uganda (AOR 0.61, 95% CI: 0.45–0.82) compared to Eastern Uganda, and exposure to newspapers and magazines.

Conclusion

The level of coverage of the complete continuum of maternal care was low and varied across regions. It was associated with easily modifiable factors such as early initiation of ANC, exposure to mass media and level of education. Interventions to improve utilisation of the continuum of maternal care should leverage mass media to promote services, especially among the least educated and the residents of Western Uganda.

Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis

BACKGROUND

Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh.

MATERIALS AND METHODS

This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association.

RESULTS

Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64).

CONCLUSION

The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.