Multilevel analysis of factors associated with assistance during delivery in rural Nigeria: implications for reducing rural-urban inequity in skilled care at delivery

Low utilization of skilled delivery services in rural sub-Saharan Africa: a case for facility delivery improvement

Maternal mortality remains a pressing global challenge, with sub-Saharan Africa (SSA) disproportionately affected. Despite efforts to improve access to skilled delivery services, utilization remains low, especially in rural areas. This paper synthesizes the extant literature and empirical evidence from rural Ghana to highlight the critical issue of low-skilled delivery services uptake in rural SSA. The literature review findings reveal a pooled prevalence of 54.9% skilled delivery services utilization, while the empirical survey in Ghana indicates a lower rate of 48.7%. These findings underscore the urgent need for targeted interventions to improve access to skilled delivery services in rural SSA. We recommend addressing harmful gender norms, evaluating existing interventions, and integrating qualitative and quantitative approaches to better understand barriers to skilled delivery services utilization in rural Africa. Urgent action is needed to ensure safer childbirth experiences and better maternal and child health outcomes in the region.

Determinants of traditional birth attendant utilisation among reproductive age women in Ethiopia: a multilevel analysis of the 2019 Ethiopian Demographic and Health Survey

OBJECTIVES

To identify the determinants of traditional birth attendants' utilisation among reproductive-age women in Ethiopia.

DESIGN

Cross-sectional study design.

SETTING

Ethiopia.

PARTICIPANTS

A total of 3979 weighted samples of reproductive-age women were included.

OUTCOME MEASURE

Traditional birth attendant utilisation.

RESULTS

This study found a high prevalence (29.76%) of Ethiopian mothers using traditional birth attendants for delivery, based on data from the 2019 Ethiopian Demographic and Health Survey. Mothers with higher education (adjusted OR (AOR)=0.11, 95% CI: 0.01 to 0.62), who had four or more antenatal care visits (AOR=0.34, 95% CI: 0.21 to 0.54), communities with lower levels of education (AOR=2.21, 95% CI: 1.30 to 3.73), communities with higher poverty levels (AOR=1.71, 95% CI: 1.99 to 2.96) and those from peripheral regions (AOR=3.41, 95% CI: 1.77 to 6.56) were found to be predictors of traditional birth attendants.

CONCLUSION

This study indicates a high prevalence (29.76%) of Ethiopian mothers using traditional birth attendants, highlighting the need for targeted interventions to promote skilled birth attendance. Policymakers should focus on implementing educational programmes targeting reproductive-age women and improving access to quality antenatal care. Specific initiatives could include community-based educational workshops and subsidies for transportation to healthcare facilities. Furthermore, mothers in remote and border districts should receive specialised attention in terms of resource allocation, including skilled personnel and enhanced healthcare access.

Regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria: A national population based cross-sectional study

BACKGROUND

Globally, about 810 women die daily from pregnancy and childbirth complications, and the burden is highest in Africa. The United Nations sustainable development goal has a maternal mortality ratio (MMR) target of 70 per 100,000 live births by 2030. Nigeria, the largest country in Africa, has an MMR of 512 per 100,000 live births, thus there is need for intensified efforts to reduce maternal deaths in the country. Proper utilisation of maternal health services including health facilities for delivery is crucial to achieving this. This study assesses the regional trends, spatial patterns and determinants of health facility delivery among women of reproductive age in Nigeria.

METHODS

This is a weighted secondary analysis of the Nigerian Demographic and Health Survey (NDHS). The sample included women who had a live birth in the preceding 5 years of the NDHS 2008, 2013 and 2018. Bivariate analysis and multilevel logistic regression were carried out to assess the determinants of health facility delivery. Trends analysis was done using bar graphs and spatial analysis showed the distribution of health facility delivery by State.

RESULTS

Forty-one percent of women delivered their last child in a health facility. The proportion of women who delivered at a health facility increased from 2008 to 2018 for all regions, with exception of the South-south region. Determinants of facility-based delivery include; ethnicity, level of education, wealth index, exposure to mass media (AOR 1.34; 95% CI 1.20-1.50), number of childbirths, number of antenatal visits (AOR 4.03; 95% CI 3.51-4.62), getting a companion to go the health facility (AOR 0.84; 95% CI 0.72-0.98), community level poverty, community level of female education, community distance to health facility, and geographical region.

CONCLUSION

There is an urgent need to deploy appropriate strategies and programme to improve health facility delivery in Nigeria.

Utilization of maternal health care services among pastoralist communities in Marsabit County, Kenya: a cross-sectional survey

BACKGROUND

Improving maternal healthcare services is crucial to achieving the Sustainable Development Goal (SDG-3), which aims to reduce maternal mortality and morbidity. There is a consensus among different researchers that proper utilization of maternal healthcare services can improve the reproductive health of women, and this can be achieved by providing Antenatal Care (ANC) during pregnancy, Health Facility Delivery (HFD), and Postnatal Care (PNC) to all pregnant women. The main aim of this study was to investigate the utilization and factors associated with maternal and child healthcare services among women of reproductive age in the pastoralist communities in Kenya.

METHODS

A cross-sectional survey was conducted among 180 pastoralist women who gave birth in the past two years across ten mobile villages in Marsabit County between 2nd January and 29th February 2019. Three key outcomes were analyzed, whether they attended ANC 4+ visits, delivered at HF, and received PNC. Pearson χ2 test and multivariate logistic regression analysis were conducted by IBM SPSS27.0 following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The significance level was set at p < 0.05.

RESULTS

Of the 180 eligible pastoralist women (mean age 27.44 ± 5.13 years), 92.2% were illiterate, 93.9% were married, 33.3% were in polygamy, and 14.4% had mobile phones. The median commuting distance was 15.00 (10-74) km, 41.7% attended ANC 4+, 33.3% HFD, and 42.8% PNC. Those women residing close (≤ 15 km) to a health facility had a threefold higher ANC 4+ (OR 3.10, 95% CI 1.47-6.53), 2.8-fold higher HFD (OR 2.80, 95% CI 1.34-5.84), and 2.5-fold higher PNC (OR 2.49, 95% CI 1.19-5.22) probability. The likelihood was 30-fold higher for ANC 4+ (OR 29.88, 95% CI 6.68-133.62), 2.5-fold higher for HFD (OR 2.56, 95% CI 0.99-6.63), and 60-fold higher for PNC (OR 60.46, 95% CI 10.43-350.55) in women with mobile phones. A monogamous marriage meant a fivefold higher ANC 4+ (OR 5.17, 95% CI 1.88-14.23), 1.6-fold higher HFD (OR 1.67, 95% CI 0.77-3.62), and a sevenfold higher PNC (OR 7.05, 95% CI 2.35-21.19) likelihood. Hosmer Lemeshow test indicated a good-fitting model for ANC 4+, HFD, and PNC (p = 0.790, p = 0.441, p = 0.937, respectively).

CONCLUSION

In conclusion, the utilization of three essential maternal health services is low. Geographic proximity, monogamous marriage, and possession of mobile phones were significant predictors. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community by providing mobile health outreach and health education.

Factors Associated with Use of Traditional Birth Attendants for Child Delivery: A Cross-Sectional Study

Background

Even though the use of skilled birth attendants at birth reduces the risk of maternal mortality and associated complications, some pregnant women prefer to use either traditional birth attendants (TBAs) or deliver at home. Although the use of assisted delivery was reduced between 2014 and 2016 in North Tongu, the rate of TBA use among pregnant women in the district was increasing. There is, therefore, the need to establish the reason for this increase in TBA use. We conducted a study to assess factors that influence the use of TBAs in the North Tongu district.

Methods

A retrospective cross-sectional facility-based survey was conducted among 449 women who delivered within the past 12 months and were accessing postnatal care services in the North Tongu district. A simple random sampling method was used to select women who attend child welfare clinics. Bivariate and multivariate analyses were conducted to determine the factors that were significantly associated with use of TBAs. All statistical analyses were done at a 95% confidence level with statistical significance at p ≤ 0.05.

Results

The mean age of the respondents was 27.0 years ± 6.2 SD. The prevalence of use of TBA during childbirth among women was 26.5%. Factors that significantly influenced use of TBAs during childbirth were age, religion, educational status, and parity. Other significant factors included several antenatal care visits and the attitude of health workers toward pregnant women.

Conclusion

Use of TBA services at birth in the study district remains relatively high. Women who use antenatal and postnatal care services should be educated on the importance of skilled delivery. There is also a need to equip TBAs and reposition them as link agents to facilitate referrals of pregnant women to health facilities where there is a need for additional birth attendants.

Contextual determinants of generational continuation of female genital mutilation among women of reproductive age in nigeria: analysis of the 2018 demographic and health survey

BACKGROUND

Female genital mutilation (FGM) has negative health implications and has long been recognised as violating sexual rights. Despite the huge efforts expended on eradicating FGM, generational continuation of the practice, i.e. the act of mutilated women also mutilating their daughters, persists in Nigeria. This study investigated the individual, household, and community factors associated with generational continuation of FGM among women in Nigeria.

METHODS

The study analysed data from the 2018 Nigeria Demographic and Health Survey (NDHS). A weighted sample of 3835 women with FGM history and who had given birth to female children was analysed. Models were estimated using mixed-effects multilevel logistic regression with Stata 16.0.

RESULTS

The results showed that 40.0% of women continued FGM for their daughters. Regional prevalence of FGM continuation ranged from 14.9% in the South-South (the lowest) to 64.3% in the North-West (the highest). Women aged 15-24 years (uaOR = 0.40; 95% CI:0.28-0.57) and rich (uaOR = 0.44; 95% CI:0.35-0.56) had the least likelihood of generational continuation of FGM. In communities with low proportions of women unexposed to the media, the likelihood of FGM continuation was significantly higher (uaOR = 1.85; 95% CI:1.35-2.53). Generational continuation of FGM was significantly lower in communities with moderate proportions of uneducated mothers (aOR = 0.6; 95% CI:0.42-0.86).

CONCLUSION

FGM continuation was high in Nigeria, and it was most common among older and poor mothers and in communities with large proportions of uneducated women and those unexposed to the media. Existing National Policy and Plan on FGM elimination should be strengthened to target these characteristics.

Women in low- and middle-income countries receive antenatal care at health institutions, yet not delivered there: a multilevel analysis of 2016-2021 DHS data

BACKGROUND

The institutional delivery dropout (IDD) is a major problem that disproportionately affects low- and middle-income countries (LMICs). It is associated with increased risks of adverse birth outcomes among pregnant women. Hence, this study assessed the pooled estimate and determinants of IDD after antenatal care (ANC) visit among women in LMICs.

METHOD

The Demographic and Health Survey (DHS) data from 29 LMICs were used for this study. Data analysis was performed with STATA version 14. The forest plot was used to estimate the pooled prevalence of IDD. Multilevel binary logistic regression was fitted to identify determinants of IDD. The statistical significance level between the outcome and independent variables was determined through the adjusted odds ratio (AOR) with 95% CI and p-value less than 0.05.

RESULT

The pooled prevalence of IDD after ANC booking among reproductive age women in LMICs was 22.25% (95%CI: 18.25, 26.25). Additionally, the prevalence of IDD was highest (29.83%) among women from the South and Central Europe and the Caribbean countries and lowest (13.72%) in Central/Western Asia and the Oceania. In the multilevel analysis; no education (AOR = 2.92; 95% CI: 2.72, 3.13), poorest wealth index (AOR = 3.46; 95% CI: 3.28, 3.66), inadequate ANC visits (AOR = 1.73; 95% CI: 1.39, 1.77), no media exposure (AOR = 1.27; 95% CI: 1.23, 1.30), rural (AOR = 1.50; 95% CI: 1.43, 1.54), distance a big problem (AOR = 1.28; 95% CI: 1.25, 1.31), and women located in the South/Eastern Europe and Caribbean region 6.67 (AOR = 6.67; 95% CI: 6.20, 7.20), women lived in low-income countries 7.05 (AOR = 7.05; 95% CI: 6.57, 7.56), and women from lower middle-income countries 5.34 (AOR = 5.57; 95% CI: 4.93, 5.78), had increased odds of IDD after ANC among women in LMICs. However, women who had ever born one child (AOR = 0.29; 95% CI: 0.28, 0.31), and women from Central and Western Asia and the Oceania (AOR = 0.78; 95%CI: 0.74, 0.82) had decreased odds of IDD.

CONCLUSION

The IDD was high among women in LMICs and significantly increased among women with no education, from poorest household, had inadequate ANC visit, no media exposure, rural, distance a big problem. Hence, interventions to reduce IDD should focus on addressing the gaps related to maternal education, access to media, and number of ANC visits among women in LMICs.

Southern Ethiopian skilled birth attendant variations and maternal mortality: A multilevel study of a population-based cross-sectional household survey

Studies examining skilled birth attendants (SBA) use and its correlation with maternal mortality at lower administrative levels are scarce. This study assessed the coverage and variations of SBA, the physical accessibility of health facilities for SBA, and the association of SBA with maternal mortality. A cross-sectional study using a population-based household survey was conducted in six Sidama National Regional State, southern Ethiopia districts, from July 2019 to May 2020. Women who had given birth in the past two years before the study were included. Stata 15 and ArcGIS 10.4.1 were used for data analysis. A multilevel logistic regression analysis was conducted to assess the effect of the sampling units and identify factors independently associated with SBA. The association between SBA and maternal mortality was examined using maternal mortality household survey data. A total of 3191 women who had given birth in the past two years and resided in 8880 households sampled for the associated maternal mortality household survey were interviewed. The coverage of SBA was 46.7%, with high variations in the districts. Thirty percent of SBA use was accounted for by the differences among the districts. One-third of the women travel more than two hours on foot to access the nearest hospital. Districts with low coverage of SBA and located far away from the regional referral centre had high maternal mortality. Education of the mother, occupation of the husband, pregnancy-related complications, use of antenatal care, parity, and distance to the nearest hospital and health centre were associated with the use of SBA. The coverage of SBA in the Sidama Region was low, with high variations in the districts. Low SBA use was associated with high maternal mortality. Due attention should be given to districts with low coverage of SBA and those located far away from the referral centre. Access to hospitals has to improve. All women should be encouraged to get antenatal care services.

Regional differences in the utilisation of antenatal care and skilled birth attendant services during the COVID-19 pandemic in Nigeria: an interrupted time series analysis

INTRODUCTION

The COVID-19 pandemic has had a substantial negative impact on the utilisation of essential health services (EHS) globally, especially in resource-limited settings such as Nigeria. High maternal deaths associated with low access to and utilisation of EHS such as antenatal care (ANC) and skilled birth attendants (SBAs) remain a concern during the COVID-19 era. The study assessed the COVID-19 pandemic effects on ANC and SBA utilisation across regions in Nigeria.

METHODS

Monthly data on ANC and SBA between January 2017 and July 2021 were obtained from the Federal Ministry of Health database. An interrupted time-series analysis, implemented using the Prophet model, was conducted to compare the regional variation of outcomes during the COVID-19 pandemic. Average percentage changes (PC) between the observed and predicted outcomes including their 95% CI were reported.

RESULTS

From March 2020 to July 2021, the number of ANC visits was significantly lower than expected by a 16%-43% change in five of the six regions in Nigeria. The highest significant reduction was in North-West (PC=-43.4; 95% CI: -52.6 to -34.1) and the least in South-West (PC=-15.5; 95% CI: -24.8 to -6.1), with no significant change in the South-East. The number of deliveries by SBA was significantly lower than expected by a 18%-43% change in all the regions (p<0.01). North-East (PC=-43.3; 95% CI: -51.7 to -34.9) and South-West (PC=-18.3; 95% CI: -25.2 to -11.5), respectively, had the highest and the least decline in SBA utilisation. Overall, ANC and SBA patterns of change were relatively similar across the north-south divide though the change effect was considerably pronounced in the north.

CONCLUSION

There was a substantial reduction in ANC and SBA utilisation due to the COVID-19 pandemic in Nigeria, especially in the northern regions. Targeted and contextually relevant interventions should be implemented to alleviate the impact of emergency response on access to EHS and promote access to care during the pandemic.

Two level logistic regression analysis of factors influencing skilled birth attendant during delivery among Bangladeshi mothers: A nationally representative sample

BACKGROUND

In order to minimize the maternal and child mortality rate, the presence of skilled birth attendants (SBA) during delivery is essential. By 2022, 4th health, population and nutrition sector programme in Bangladesh aims to increase the percentage of deliveries performed by SBA to 65 percent. The objective of the present study was to determine the rate and associated factors of usage SBA among Bangladeshi mothers during their delivery.

METHODS

This study utilized secondary data that was collected by Bangladesh Demographic and Health Survey (BDHS) 2017-18. The usage of SBA was measured by a question to respondent, who assisted during your delivery? It was classified into two classes; (i) skilled birth attendant (qualified doctors, nurses, midwives, or paramedics; family welfare visitors, community skilled birth attendants, and sub-assistant community medical officers) (code 1), and (ii) unskilled birth attendant (untrained traditional birth attendants, trained traditional birth attendants, relatives, friends, or others) (code 0). Two logistic regression model was used to determine the associated factors of SBA after removing the cluster effect of the outcome variable.

RESULTS

This study found 53.2% mothers were delivered by SBA in Bangladesh, among them 56.33% and 42.24% mothers were delivered by nurse/midwife/paramedic and doctor respectively. The two level logistic model demonstrated that geographical location (division), type of residence, religion, wealth index, mothers' body mass index, mothers' education level, mothers' occupation, total ever born children, mothers' age at first birth (year), number of ANC visits, husbands' education level and husbands' occupation were significant (p<0.01) predictors of SBA. Mothers' education and wealth index were the most important contributory factors for SBA in Bangladesh.

CONCLUSIONS

This study revealed that still 46.8% mothers are delivered by unskilled birth attendant, this might be treated of Bangladesh Government to achieve SDGs indicator 3.1.2 by 2030. Counseling could be integrated during ANC to increase awareness, and should ensure for every Bangladeshi mothers visit ANC service during their pregnancy at least 4 times.

Determinants of health facility delivery among young mothers aged 15 - 24 years in Nigeria: a multilevel analysis of the 2018 Nigeria demographic and health survey

BACKGROUND

Young mothers aged 15 to 24 years are particularly at higher risk of adverse health outcomes during childbirth. Delivery in health facilities by skilled birth attendants can help reduce this risk and lower maternal and perinatal morbidity and mortality. This study assessed the determinants of health facility delivery among young Nigerian women.

METHODS

A nationally representative population data extracted from the 2018 Nigeria Demographic and Health Survey of 5,399 young women aged 15-24 years who had had their last birth in the five years before the survey was analysed. Data was described using frequencies and proportions. Bivariate and multivariate analyses were carried out using Chi-Square test and multilevel mixed effect binary logistic regression. All the analysis were carried out using STATA software, version 16.0 SE (Stata Corporation, TX, USA)..

RESULTS

Of the total sampled women in the 2018 NDHS, 5,399 (12.91%) formed our study population of young women 15 -24 years who had their last birth in the preceding five years of the survey. Only 33.72% of the young mothers utilized health facility for delivery. Women educated beyond the secondary school level had 4.4 times higher odds of delivering at a health facility compared with women with no education (AOR 4.42 95%, CI 1.83 - 10.68). Having fewer children and attending more antenatal visits increased the odds of health facility delivery. With increasing household wealth index, women were more likely to deliver in a health facility. The odds of health facility delivery were higher among women whose partners had higher than secondary level of education. Women who lived in communities with higher levels of female education, skilled prenatal support, and higher levels of transportation support were more likely to deliver their babies in a health facility.

CONCLUSION

Strategies to promote institutional delivery among young mothers should include promoting girl child education, reducing financial barriers in access to healthcare, promoting antenatal care, and improving skilled birth attendants and transportation support in disadvantaged communities.

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.

Enablers and barriers to the acceptability of mHealth for maternal healthcare in rural Edo, Nigeria

Objective

Acceptability has become a key consideration in designing, implementing and evaluating digital health interventions. Current evidence points to acceptability as a crucial factor in sustaining mobile health programs for maternal health across sub-Saharan Africa particularly in Nigeria where the burden of maternal mortality is high. This paper describes the enablers and barriers to the acceptance of Text4Life, a mobile phone-based health intervention that extends maternal healthcare services to rural areas of Edo State Nigeria.

Method

This is a cross-sectional qualitative study of women who used Text4Life, their spouses who were all men and Ward Development Committee chairpersons who oversaw the implementation of Text4Life. This study was set in Etsako East and Esan Central Local Government Areas of Edo State, Nigeria. Between September 2021 and January 2022, eight focus groups were conducted with 64 participants: 39 women and 25 men. Two in-depth interviews were conducted with Ward Development Committee chairpersons. Data collection was conducted in English and Pidgin English. Discussions and interviews were digitally recorded and translated to English from Pidgin English where necessary. Data analysis followed a mainly deductive approach to thematic analysis, however, emergent information from the data was also considered and reported.

Results

The results show that participants' positive attitudes towards the intervention, the involvement of the community, participants' understanding of the intervention, and perceived effectiveness of the Text4Life program were enablers to women's acceptance of Text4Life and enablers to Ward Development Committee chairpersons' assistance with the program. On the other hand, limited resources and a clash with the community's value system presented barriers to the acceptability of the Text4Life program.

Conclusion

Our findings demonstrate the importance of alleviating the burdens associated with participating in mobile health interventions while noting that the risk of obstructing the gains from mobile health interventions is high if plans for sustaining it are not incorporated early enough in the design phase.

Distance is “a big problem”: a geographic analysis of reported and modelled proximity to maternal health services in Ghana

Background

Geographic barriers to healthcare are associated with adverse maternal health outcomes. Modelling travel times using georeferenced data is becoming common in quantifying physical access. Multiple Demographic and Health Surveys ask women about distance-related problems accessing healthcare, but responses have not been evaluated against modelled travel times. This cross-sectional study aims to compare reported and modelled distance by socio-demographic characteristics and evaluate their relationship with skilled birth attendance. Also, we assess the socio-demographic factors associated with self-reported distance problems in accessing healthcare.

Methods

Distance problems and socio-demographic characteristics reported by 2210 women via the 2017 Ghana Maternal Health Survey were included in analysis. Geospatial methods were used to model travel time to the nearest health facility using roads, rivers, land cover, travel speeds, cluster locations and health facility locations. Logistic regressions were used to predict skilled birth attendance and self-reported distance problems.

Results

Women reporting distance challenges accessing healthcare had significantly longer travel times to the nearest health facility. Poverty significantly increased the odds of reporting challenges with distance. In contrast, living in urban areas and being registered with health insurance reduced the odds of reporting distance challenges. Women with a skilled attendant at birth, four or more skilled antenatal appointments and timely skilled postnatal care had shorter travel times to the nearest health facility. Generally, less educated, poor, rural women registered with health insurance had longer travel times to their nearest health facility. After adjusting for socio-demographic characteristics, the following factors increased the odds of skilled birth attendance: wealth, health insurance, higher education, living in urban areas, and completing four or more antenatal care appointments.

Conclusion

Studies relying on modelled travel times to nearest facility should recognise the differential impact of geographic access to healthcare on poor rural women. Physical access to maternal health care should be scaled up in rural areas and utilisation increased by improving livelihoods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04998-0.

Spatial and multilevel analysis of unskilled birth attendance in Chad

Background

Unskilled birth attendance is a major public health concern in Sub-Saharan Africa (SSA). Existing studies are hardly focused on the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad (a country in SSA), although the country has consistently been identified as having one of the highest prevalence of maternal and neonatal deaths in the world. This study aimed to analyse the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad.

Methods

The study is based on the latest Demographic and Health Survey (DHS) data for Chad. A total of 10,745 women aged between 15 and 49 years were included in this study. A multilevel analysis based on logistic regression was conducted to estimate associations of respondents’ socio-demographic characteristics with unskilled birth attendance. Geographic Information System (GIS) mapping tools, including Getis-Ord Gi hotspot analysis tool and geographically weighted regression (GWR) tool, were used to explore areas in Chad with a high prevalence of unskilled birth attendance.

Results

The findings show that unskilled birth attendance was spatially clustered in four Chad departments: Mourtcha, Dar-Tama, Assoungha, and Kimiti, with educational level, occupation, birth desire, birth order, antenatal care, and community literacy identified as the spatial predictors of unskilled birth attendance. Higher educational attainment, higher wealth status, cohabitation, lowest birth order, access to media, not desiring more births, and higher antenatal care visits were associated with lower odds of unskilled birth attendance at the individual level. On the other hand, low community literacy level was associated with higher odds of unskilled birth attendance in Chad whereas the opposite was true for urban residency.

Conclusions

Unskilled birth attendance is spatially clustered in some parts of Chad, and it is associated with various disadvantaged individual and community level factors. When developing interventions for unskilled birth attendance in Chad, concerned international bodies, the Chad government, maternal health advocates, and private stakeholders should consider targeting the high-risk local areas identified in this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13972-6.

Individual and community-level factors associated with skilled birth attendants during delivery in Bangladesh: A multilevel analysis of demographic and health surveys

Background

Skilled birth attendants (SBAs) play a crucial role in reducing infant and maternal mortality. Although the ratio of skilled assistance at birth has increased in Bangladesh, factors associated with SBA use are unknown. The main goal of our study was to reveal the individual- and community-level factors associated with SBA use during childbirth in Bangladesh. We also showed the prevalence and trend of SBA use and related independent variables in Bangladesh over the past decade.

Methods

This study utilized the Bangladesh Health and Demographic Survey (BDHS) 2017–2018, a cross-sectional study. We used binary logistic regression to examine the extent of variation in SBA use attributable to the individual- and community-level variables.

Results

Overall, 53.35% of women received assistance from SBAs during childbirth. The average annual rate of increase (AARI) in the number of SBA-assisted births over the past 10 years was 8.88%. Respondents who gave birth at or above 19 years had 1.40 times (AOR = 1.40; 95% CI: 1.21–1.62) greater odds of having skilled delivery assistance than respondents aged 18 years old or less. Women and their husband’s education levels were significantly associated with using skilled assistance during delivery, with odds of 1.60 (AOR = 1.60; 95% CI: 1.45–2.01) and 1.41 (AOR = 1.41; 95% CI: 1.21–1.66), respectively compared to those with education up to primary level. Women from rich families and those receiving better antenatal care (ANC) visits were more likely to have professional delivery assistance. Community-level factors also showed significance towards having professional assistance while giving birth. Women from urban communities and those who utilized more than four ANC visits and had completed secondary or higher education showed a greater tendency to use an SBA during childbirth than their counterparts.

Conclusion

The use of SBAs during delivery was significantly associated with some individual- and community-level factors. To reduce maternal and child mortality, there is a need to focus on rural and uneducated people who are less likely to access these facilities. Special programs could increase awareness and help the poor community obtain the minimum facility in maternal care.

Delivery Services Utilization Based on Urban Rural Status in Indonesia

INTRODUCTION: Maternal mortality has been listed in the Sustainable Development Goals’ priority. Hence, use of delivery services from health facilities is essential to improve maternal and child health. AIM: This study aimed to analyze the trends and determinants of delivery service utilization between urban and rural areas in Indonesia. METHODS: This quantitative study uses a cross-sectional design. The secondary data source came from the Indonesian Health Demographic Survey (IDHS) in 2007-2017. As many as 29,985 married women of childbearing age (15-49 years old) were selected as samples. The data analysis was done using the chi-square test then binary logistic regression test. RESULTS: Trends in the utilization of health facility delivery services increased in Indonesia. Age, residential area, education level, occupational status, antenatal visits and knowledge of danger signs during pregnancy, and economic status were associated with the utilization of health facility delivery services both in the rural and urban areas. Women who finished college had 4.55 times chances of using health facility delivery services  CONCLUSION: Demographic characteristics, antenatal visits, and knowledge of danger signs during pregnancy are associated with use of health facility delivery service sin rural and urban areas. The government needs to consider these factors in reducing inequal use of health facility delivery services between urban and rural areas.

Factors Associated With Home Births in Benin and Mali: Evidence From the Recent Demographic and Health Surveys

Introduction

Identifying and understanding the factors associated with homebirths can contribute to improving maternal and child health and achieving the Sustainable Development Goals (SDGs). This study aimed to perform a comparative analysis of the factors associated with homebirths in Benin and Mali.

Method

This study is based on the most recent data from the Demographic Health Surveys conducted in Mali and Benin in 2018. The dependent variable was homebirth, and the explanatory variables were the individual characteristics of the woman, the distance to the health center, the place of residence, the number of prenatal consultations had, the frequency of media exposure, and the use of the Internet. The primary survey unit (PSU) was considered in the analysis to measure the effect of context on the choice of the place of delivery. Further, descriptive statistics and multilevel logistic regression analysis were used in the study.

Results

Educational level was associated with homebirth in Benin and Mali; Women with either no education or primary education are more likely to give birth at home. Women who didn't live close to a health facility were more likely to give birth at home than those who didn't face this problem in both countries. Not making visits for antenatal care (ANC) increases the odds of having a homebirth by 31.3 times (CI = 24.10-40.70) in Benin and 12.91 times (CI = 10.21-16.33) in Mali. Similarly, women who went on 1-2 ANC visits were more likely to give birth at home compared with women who made five or more ANC visits in both countries. The number of children per woman was also a significant factor in both countries. Women who often or regularly paid attention to the media messages were less likely to give birth at home compared with those who did not follow relevant media inputs (aOR = 0.42 [CI = 0.26-0.67] in Benin and aOR = 0.65 [CI = 0.50-0.85] in Mali).

Conclusion

Increasing the demand and uptake of women's health services by improving the availability and quality of services and establishing community health centers could help reduce the incidence of homebirths that can be risky and, thus, combat maternal and infant mortality.

Female genital mutilation and skilled birth attendance among women in sub-Saharan Africa

BACKGROUND

There is evidence that women who have had their genitals cut suffer substantial difficulties during and/or after childbirth, including the need for a caesarean section, an episiotomy, an extended hospital stay, post-partum bleeding, and maternal fatalities. Whether or not women in sub-Saharan Africa who have undergone female genital mutilation utilize the services of skilled birth attendants during childbirth is unknown. Hence, we examined the association between female genital mutilation and skilled birth attendance in sub-Saharan Africa.

METHODS

The data for this study were compiled from 10 sub-Saharan African countries' most recent Demographic and Health Surveys. In the end, we looked at 57,994 women between the ages of 15 and 49. The association between female genital mutilation and skilled birth attendance was investigated using both fixed and random effects models.

RESULTS

Female genital mutilation and skilled birth attendance were found to be prevalent in 68.8% and 58.5% of women in sub-Saharan Africa, respectively. Women with a history of female genital mutilation had reduced odds of using skilled birth attendance (aOR = 0.91, 95% CI = 0.86-0.96) than those who had not been circumcised. In Ethiopia, Guinea, Liberia, Kenya, Nigeria, Senegal, and Togo, women with female genital mutilation had reduced odds of having a trained delivery attendant compared to women in Burkina Faso.

CONCLUSION

This study shed light on the link between female genital mutilation and skilled birth attendance among sub-Saharan African women. The study's findings provide relevant information to government agencies dealing with gender, children, and social protection, allowing them to design specific interventions to prevent female genital mutilation, which is linked to non-use of skilled birth attendance. Also, health education which focuses on childbearing women and their partners are necessary in enhancing awareness about the significance of skilled birth attendance and the health consequences of female genital mutilation.

A multilevel analysis of individual and contextual factors associated with the practice of safe disposal of children's faeces in sub-Saharan Africa

Background

Over the years, sanitation programs over the world have focused more on household sanitation, with limited attention towards the disposal of children’s stools. This lack of attention could be due to the misconception that children’s stools are harmless. The current study examined the individual and contextual predictors of safe disposal of children’s faeces among women in sub-Saharan Africa (SSA).

Methods

The study used secondary data involving 128,096 mother-child pairs of under-five children from the current Demographic and Health Surveys (DHS) in 15 sub-Saharan African countries from 2015 to 2018. Multilevel logistic analysis was used to assess the individual and contextual factors associated with the practice of safe disposal of children’s faeces. We presented the results as adjusted odds ratios (aOR) at a statistical significance of p< 0.05.

Results

The results show that 58.73% (57.79–59.68) of childbearing women in the 15 countries in SSA included in our study safely disposed off their children’s stools. This varied from as high as 85.90% (84.57–87.14) in Rwanda to as low as 26.38% (24.01–28.91) in Chad. At the individual level, the practice of safe disposal of children’s stools was more likely to occur among children aged 1, compared to those aged 0 [aOR = 1.74; 95% CI: 1.68–1.80] and those with diarrhoea compared to those without diarrhoea [aOR = 1.17, 95% CI: 1.13–1.21]. Mothers with primary level of education [aOR = 1.42, 95% CI: 1.30–1.5], those aged 35–39 [aOR = 1.20, 95% CI: 1.12–1.28], and those exposed to radio [aOR = 1.23, 95% CI: 1.20–1.27] were more likely to practice safe disposal of children’s stools. Conversely, the odds of safe disposal of children’s stool were lower among mothers who were married [aOR = 0.74, 95% CI: 0.69–0.80] and those who belonged to the Traditional African Religion [aOR = 0.64, 95% CI: 0.51–0.80]. With the contextual factors, women with improved water [aOR = 1.13, 95% CI: 1.10–1.16] and improved toilet facility [aOR = 5.75 95% CI: 5.55–5.95] had higher odds of safe disposal of children’s stool. On the other hand, mothers who lived in households with 5 or more children [aOR = 0.89, 95% CI: 0.86–0.93], those in rural areas [aOR = 0.86, 95% CI: 0.82–0.89], and those who lived in Central Africa [aOR = 0.19, 95% CI: 0.18–0.21] were less likely to practice safe disposal of children’s stools.

Conclusion

The findings indicate that between- and within-country contextual variations and commonalities need to be acknowledged in designing interventions to enhance safe disposal of children’s faeces. Audio-visual education on safe faecal disposal among rural women and large households can help enhance safe disposal. In light of the strong association between safe stool disposal and improved latrine use in SSA, governments need to develop feasible and cost-effective strategies to increase the number of households with access to improved toilet facilities.

"We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria

OBJECTIVE

The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria.

DESIGN

This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery.

SETTING

The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria.

PARTICIPANTS

The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter.

RESULTS

Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints.

CONCLUSION

This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.

To what extent do community characteristics drive health facility delivery? Findings among Women who had recent live births in Nigeria

Existing studies have established several individual drivers of health facility delivery in many developing countries. However, the community characteristics that drive health facility delivery have been less studied across developing countries. This study thus examines the extent to which community characteristics drives health facility delivery among women who had recent live births in Nigeria based on data from the 2018 Nigeria Demographic and Health Survey (NDHS). A weighted sample size of 7,342 women was analysed. The outcome variable was health facility delivery. The explanatory variables were selected individual and community characteristics. Results show 39.7% prevalence of health facility delivery among the women. Findings further reveals that the community characteristics have significant effects on the variations in health facility delivery across the communities. Community characteristics significantly drive health facility delivery in Nigeria. More community-based priority actions are required to improve demand for health facility delivery in the country.

Multilevel geospatial analysis of factors associated with unskilled birth attendance in Ghana

Background

Globally, about 810 women die every day due to pregnancy and its related complications. Although the death of women during pregnancy or childbirth has declined from 342 deaths to 211 deaths per 100,000 live births between 2000 and 2017, maternal mortality is still higher, particularly in sub-Saharan Africa and South Asia, where 86% of all deaths occur.

Methods

A secondary analysis was carried out using the 2014 Ghana Demographic and Health Survey. A sample total of 4,290 women who had a live birth in the 5 years preceding the survey was included in the analysis. GIS software was used to explore the spatial distribution of unskilled birth attendance in Ghana. The Geographic Weighted Regression (GWR) was employed to model the spatial relationship of some predictor of unskilled birth attendance. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with unskilled birth attendance.

Results

In this study, unskilled birth attendance had spatial variations across the country. The hotspot, cluster and outlier analysis identified the concerned districts in the north-eastern part of Ghana. The GWR analysis identified different predictors of unskilled birth attendance across districts of Ghana. In the multilevel analysis, mothers with no education, no health insurance coverage, and mothers from households with lower wealth status had higher odds of unskilled birth attendance. Being multi and grand multiparous, perception of distance from the health facility as not a big problem, urban residence, women residing in communities with medium and higher poverty level had lower odds of unskilled birth attendance.

Conclusion

Unskilled birth attendance had spatial variations across the country. Areas with high levels of unskilled birth attendance had mothers who had no formal education, not health insured, mothers from poor households and communities, primiparous women, mothers from remote and border districts could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.

Empirical linkages between female genital mutilation and multiple sexual partnership: evidence from the 2018 Mali and 2013 Sierra Leone Demographic and Health Surveys

Female genital mutilation (FGM) is very pervasive in Africa, with significant regional variations in the prevalence of this traditional practice. This study examined the linkages between FGM and multiple sexual partnership in Mali and Sierra Leone - two African countries with a high prevalence of FGM. Data were from the 2018 Mali and 2013 Sierra Leone Demographic and Health Surveys, and the study sample comprised 4750 women from Mali and 16,614 from Sierra Leone. Multilevel logistic regression was used for the data analysis, with reported adjusted odds ratios (aOR) and associated 95% confidence intervals. In Mali, women who had not undergone FGM were less likely to have multiple sexual partners (aOR=0.60, CI=0.38-0.96) compared with those who had undergone FGM. In Sierra Leone, women who had undergone FGM (aOR=1.15, CI=1.02-1.30) were more likely to have multiple sexual partners compared with those who had not undergone FGM. Age, level of education, wealth quintile, sex of household head, community socioeconomic status, mass media exposure, and community literacy level were found to be associated with the likelihood of multiple sexual partnership among women in Mali and Sierra Leone. Comprehensive, age-group-based risk-reduction strategies, such as abstinence education and decision-making skills (assertiveness) training, are needed to reduce girls' and young women's engagement in multiple sexual partnerships. Policy interventions, such as anti-FGM legislation and initiatives like the 'Schooling for the Female Child' initiative aimed at reducing social inequality among girls and women, might help decrease FGM and the likelihood of health-compromising behaviours like multiple sexual partnership.

Factors associated with the utilisation of skilled delivery services in Papua New Guinea: evidence from the 2016-2018 Demographic and Health Survey

BACKGROUND

We sought to determine the prevalence and factors associated with the use of skilled assistance during delivery in Papua New Guinea.

METHODS

We analysed nationally representative data from 5210 women in Papua New Guinea using the 2016-2018 Demographic and Health survey. Both bivariate and multivariable analyses were performed. Statistical significance was set at p<0.05.

RESULTS

The prevalence of skilled assistance during delivery was 57.6%. The richest women (adjusted OR [AOR]=3.503, 95% CI 2.477 to 4.954), working women (AOR=1.221, 95% CI 1.037 to 1.439), women with primary (AOR=1.342, 95% CI 1.099 to 1.639), secondary or higher education (AOR=2.030, 95% CI 1.529 to 2.695), women whose partners had a secondary or higher level of education (AOR=1.712, 95% CI 1.343 to 2.181], women who indicated distance was not a big problem in terms of healthcare (AOR=1.424, 95% CI 1.181 to 1.718), women who had ≥4 antenatal care (ANC) visits (AOR=10.63, 95% CI 8.608 to 13.140), women from the Islands region (AOR=1.305, 95% CI 1.045 to 1.628), those who read newspapers or magazines (AOR=1.310, 95% CI 1.027 to 1.669) and women who watched television (AOR=1.477, 95% CI 1.054 to 2.069) less than once a week had higher odds of utilising skilled attendants during delivery. On the contrary, women in the Momase region (AOR=0.543, 95% CI 0.438 to 0.672), women in rural areas (AOR=0.409, 95% CI 0.306 to 0.546), as well as women with a parity of 3 (AOR=0.666, 95% CI 0.505 to 0.878) or ≥4 (AOR=0.645, 95% CI 0.490 to 0.850) had lower odds of utilising skilled attendance during delivery.

CONCLUSION

There is relatively low use of skilled delivery services in Papua New Guinea. Wealth, employment status, educational level, parity and number of ANC visits, as well as access to healthcare and place of residence, influence the utilisation of skilled delivery services.

Do the determinants of institutional delivery among childbearing women differ by health insurance enrolment? Findings from a population-based study in Nigeria

Studies in Nigeria have identified several individual and contextual determinants of institutional delivery among childbearing women. However, it is not clear in literature whether these determinants are peculiar to women who enrolled or do not enrolled in health insurance schemes. This study compares the determinants of institutional delivery among childbearing women who either enrolled or do not enrolled in health insurance schemes in Nigeria. The study was based on women's data from the 2018 Nigeria Demographic and Health Survey. A weighted sample size of 17,465 women was analysed. Stata 14 was used to perform data analysis. Three binary logistic regression models were estimated. Results show higher prevalence of institutional delivery among women who enrolled in health insurance (39.3% vs. 70.5%). Result further reveal differences in the determinants of institutional delivery among the women with sex of head of household (adjusted odds ratio [AOR] = 1.340, p < 0.05; 95% CI: 1.121-1.602), type of marriage (AOR = 0.817, p < 0.05; 95% CI: 0.727-0.918) and status of most recent delivery (AOR = 0.703, p < 0.001; 95% 95% CI: 0.631-0.781) showing significance among women not enrolled in health insurance but insignificant among women enrolled in health insurance. Differences in determinants of institutional delivery among the women may be attributed to differences in their socio-demographic condition.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria

Background

The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country’s very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women’s access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women’s use of skilled pregnancy care in rural Edo State, Nigeria.

Methods

This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches.

Results

Stakeholders identified barriers to pregnant women’s use of skilled pregnancy care and they include; financial constraints, women’s lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women’s use of skilled pregnancy care.

Conclusions

This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women’s health behaviour. Therefore, initiatives seeking to improve pregnant women’s use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

Determinants of antenatal care and skilled birth attendance services utilization among childbearing women in Guinea: evidence from the 2018 Guinea Demographic and Health Survey data

BACKGROUND

Globally, maternal health remains a major priority. Most of maternal deaths globally occur in sub-Saharan Africa, with most of these deaths linked to lack of access to antenatal care and skilled assistance during delivery. This study assessed the determinants of antenatal care and skilled birth attendance services utilization among childbearing women in Guinea.

METHODS

Data for this study were obtained from the 2018 Guinea Demographic and Health Survey (GDHS). Data of 4,917 childbearing women were considered as our analytical sample. The outcome variables for the study were utilization of antenatal care and skilled birth attendance. Analysis was carried out using chi-square tests and multivariable logistic regression.

RESULTS

The results showed that women aged 15-24 (AOR=1.29, CI=1.03-1.62), women who had secondary/higher level of education (AOR=1.70, CI=1.33-2.19), and those whose partners had secondary/higher level of education (AOR=1.46, CI=1.22-1.75), women in the richest wealth quintile (AOR=5.09, CI=3.70-7.00), those with planned pregnancies (AOR=1.50, CI=1.23-1.81), Muslim women (AOR=1.65, CI=1.38-2.12), those who take healthcare decisions alone (AOR=1.53, CI=1.24-1.89), and those who listened to radio less than once a week (AOR= 1.30, CI=1.10-1.53) had higher odds of antenatal care uptake. Also, women with secondary/higher level of education (AOR=1.83, CI=1.25-2.68), those whose partners had secondary/higher level of education (AOR=1.40, CI=1.11-1.76), those in the richest wealth quintile (AOR=10.79, CI=6.64-17.51), those with planned pregnancies (AOR=1.25, CI=1.03-1.52), Christian women (AOR=4.13, CI=3.17-5.39), those living in urban areas (AOR=3.00, CI=2.29-3.94), women with one birth (AOR= 1.58, CI=1.20-2.06), those who take healthcare decisions alone (AOR=1.87, CI=1.46-2.39), those who read newspaper at least once a week (AOR= 1.19, CI=1.01-1.40), those who watched television at least once week (AOR=1.69, CI=1.30-2.19), and those in female-headed households (AOR=1.52, CI=1.20-1.92) were more likely to utilize the services of skilled birth attendants.

CONCLUSION

The study proved that various socio-economic and contextual factors influence antenatal care and skilled birth attendance in Guinea. These findings suggest the need to design community-based interventions (e.g., miniature local ANC clinics, early screening services) that prioritize women's education and vocational training, media accessibility, especially among the poor, and those residing in rural settings. Such interventions should not ignore the influence of other socio-cultural norms that hinder the utilization of antenatal care and skilled birth attendance services in Guinea.

Individual and community socioeconomic factors related to the quality of antenatal care: a multilevel analysis of West and Central Africa

Antenatal care (ANC) can improve maternal health. We examined associations of individual and community socioeconomic status (SES) with the quality of ANC in West and Central Africa. Data were from the 2009-2011 UNICEF Multiple Indicator Cluster Surveys for women in seven countries (n = 24,718). Individual SES variables included women's education and wealth; community SES was defined as low or high poverty index. ANC quality was defined as receiving six services: blood pressure monitoring, blood tests, urine tests, malaria prophylaxis, tetanus vaccine, and HIV screening, and coded low or high. We used multilevel logistic regression to estimate fixed and random effects of individual and community SES on ANC quality. Less than one-fourth of women received high-quality ANC. Only small percentages of women had malaria prophylaxis and were counseled and tested for HIV. In adjusted country-stratified results, living in a poor community was associated with reduced odds of receiving high-quality ANC in six countries (Central African Republic: odds ratio, OR = 0.76; 95% confidence interval, CI:0.58-0.98; Chad: OR = 0.48; CI:0.32-0.74; Ghana: OR = 0.86; CI:0.61-0.97; Nigeria: OR = 0.74; CI:0.61-0.92; Sierra Leone: OR = 0.71; CI:0.57-0.91; and Togo: OR = 0.80; CI:0.47-0.91). The health system may be missing important opportunities to provide high-quality ANC and, thereby, improve pregnancy outcomes in these settings.

Exploring spatial variations and factors associated with skilled birth attendant delivery in Ethiopia: geographically weighted regression and multilevel analysis

BACKGROUND

Skilled birth attendant (SBA) delivery is vital for the health of mothers and newborns, as most maternal and newborn deaths occur at the time of childbirth or immediately after birth. This problem becomes worsen in Ethiopia in which only 28% of women give birth with the help of SBA. Therefore, this study aimed to explore the spatial variations of SBA delivery and its associated factors in Ethiopia.

METHODS

A secondary analysis was carried out using the 2016 Ethiopian Demographic and Health Survey. A total weighted sample of 11,023 women who had a live birth in the 5 years preceding the survey was included in the analysis. Arc-GIS software was used to explore the spatial distribution of SBA and a Bernoulli model was fitted using SaTScan software to identify significant clusters of non-SBA delivery. The Geographic Weighted Regression (GWR) was employed in modeling spatial relationships. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with SBA delivery.

RESULTS

In this study, SBA delivery had spatial variations across the country. The SaTScan spatial analysis identified the primary clusters' spatial window in southeastern Oromia and almost the entire Somalia. The GWR analysis identified different predictors of non- SBA delivery across regions of Ethiopia. In the multilevel analysis, mothers having primary and above educational status, health insurance coverage, and mothers from households with higher wealth status had higher odds of SBA delivery. Being multi and grand multiparous, perception of distance from the health facility as big problem, rural residence, women residing in communities with medium and higher poverty level, and women residing in communities with higher childcare burden had lower odds of SBA delivery.

CONCLUSION

Skilled birth attendant delivery had spatial variations across the country. Areas with non-skilled birth attendant delivery and mothers who had no formal education, not health insured, mothers from poor households and communities, Primiparous women, mothers from remote areas, and mothers from communities with higher childcare burden could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.

Rising cesarean deliveries in India: medical compulsions or convenience of the affluent?

From 2005-06 to 2015-16, proportion of cesarean deliveries in total deliveries has almost doubled in India. In this paper, we study changes in prevalence of cesarean deliveries across different social-economic groups and study factors affecting odds of undergoing cesarean delivery. The present paper was based on National Family Health Surveys and employs logistic regression. We find that rise in cesarean deliveries has been across social groups, religions, urban/rural India, wealth groups, though increase has not been uniform. Further, many economically affluent states have high proportion of cesarean deliveries. We find that women delivering at private hospitals had significantly higher odds of opting for cesarean delivery. Further, women belonging to rich households were more likely to go through surgery for birth. In case of earlier terminated pregnancies, odds were higher too. The higher odds of cesarean sections in the relatively affluent geographic regions, richer households and private institutions indicate that these procedures may be driven by non-medical reasons in many cases, pointing toward the use of surgical procedures for the convenience.