Associations of antenatal care visit with utilization of institutional delivery care services in Afghanistan: intersections of education, wealth, and household decision-making autonomy

Utilization of maternal healthcare services in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal mortality is a critical public health issue, especially in low- and middle-income countries (LMICs). Maternal healthcare services (MHS), including antenatal care (ANC) visits, skilled birth attendants (SBA), institutional delivery (ID), and postnatal care (PNC), are crucial policy priorities to address maternal mortality and improve pregnancy outcomes. This systematic review and meta-analysis aimed to provide a comprehensive, quantitative analysis of MHS utilization among women in LMICs.

METHODS

We conducted a comprehensive search on PubMed, Scopus, Web of Science, CINAHL, and SocINDEX to gather relevant studies on the utilization of MHS in LMICs conducted between January 2015 and December 2024. These were then synthesized both quantitatively and qualitatively and random-effect models were employed to obtain pooled estimates.

RESULTS

A total of 145 studies included in this review. Coverage of at least one ANC visit (ANC1), at least four ANC visits (ANC4), SBA, ID and PNC were reported in 66, 108, 42, 63, and 37 studies respectively and for these studies pooled prevalences of ANC1, ANC4, SBA, ID, and PNC were found 85.0% (95% CI 81.2-88.1%), 50.8% (95% CI 46.4-55.2%), 65.6% (95% CI 58.7-71.9%), 66.9% (95% CI 60.3-72.9%), and 48.9% (95% CI 41.7-56.2%), respectively, with high heterogeneity among the studies (I2 > 99.0%). Results obtained from the sub-group analysis revealed that the prevalence of MHS indicators was higher in the South and Southeast Asia (SSEA) region compared to Sub-Saharan Africa (SSA), except for ID, e.g., SBA prevalence in SSEA was 70.1% (95% CI 60.4-78.3%) whereas for SSA it was 64.0% (95% CI 53.3-73.6%). The prevalence of all MHS indicators was higher for studies with primary data than those with secondary data, except for ANC4 and PNC. Overall, associations were reported between MHS utilization and women's age, education level, household socioeconomic status, place of residence, decision-making power, and exposure to mass media.

CONCLUSION

High heterogeneity among studies infer possible disparities in MHS utilization at both global and national levels. Hence, it is crucial for policies to prioritize enhancing effective coverage, narrowing disparities, and improving care quality in alignment with the Sustainable Development Goals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023401745.

Exploration of urban-rural disparities in institutional delivery in Bangladesh: Assessing the effect of antenatal care dynamics

Background

Improving access to institutional delivery is crucial for reducing maternal and newborn mortality. However, government efforts to enhance maternal healthcare in low- and middle-income countries (LMICs) like Bangladesh mostly contribute to a significant increase in antenatal care (ANC) uptake, while institutional delivery rates remains low, with notable urban-rural differences. We, therefore, explored the association of the place, timing, and quality of ANC with the uptake of institutional delivery services, as well as explored the urban-rural differences in these associations.

Methods

The study analysed data of 3,549 mothers, extracted from the 2022 Bangladesh Demographic and Health Survey (BDHS). The outcome variable was the utilisation of institutional delivery (yes, no). The timing, location and quality of ANC were considered as the key exposure variables. A multilevel mixed-effects Poisson regression model was employed to explore associations between the outcome and the exposures. Additionally, an urban-rural differential analysis was conducted to assess the urban-rural differences in the association between exposure and outcome variables.

Results

We observed a noticeable difference in institutional delivery rates between urban (76.3%) and rural areas (60.5%), with an overall rate of 64.7%. Women who accessed ANC in the 2nd or 3rd trimester were less likely to have an institutional delivery (aPR: 0.92 and 0.74) compared to those who initiated ANC in the 1st trimester. Receiving ANC at home significantly decreased the likelihood of institutional delivery (aPR: 0.74), while ANC from private or public facilities showed no significant association. Additionally, having at least one ANC visit from a medically trained provider (MTP) significantly increased the likelihood of institutional delivery (aPR: 1.83). Receiving quality ANC services also found increasing the likelihood of institutional delivery (aPR: 1.21), with these effects being more pronounced among rural women. The urban-rural differential analysis revealed no significant variation in the determinants of institutional delivery, except for the timing of ANC initiation.

Conclusion

Urban-rural differences in institutional delivery rates are evident, with early ANC initiation, home-based ANC, and visits with MTPs being associated with higher institutional delivery rates. Initiation of ANC was the only determinant showing significant urban-rural variation, with notable differences in effect size for all other determinants. Therefore, to increase institutional delivery rates, particularly in rural areas, focusing on early initiation of ANC visits is important. In addition, improving the access to quality ANC services in the rural healthcare facilities is particularly crucial to increase the institutional delivery rates.

Quality of antenatal care services in Afghanistan: findings from the national survey 2022-2023

BACKGROUND

The optimum use of antenatal care (ANC) services can reduce pregnancy-related complications and deaths. However, there is limited information on the quality of ANC services in Afghanistan. This study aimed to assess the quality of ANC services and examine the influence of sociodemographic factors on the quality of ANC services received by pregnant women in Afghanistan.

METHODS

This study analyzed the data from the 2022-23 Afghanistan Multiple Indicators Cluster Survey (MICS), including 9,243 ever-married women aged 15-49 years who had given birth two years prior to the survey. ANC quality was classified as "good" if a woman had at least four ANC visits, initiated ANC during the first trimester, and received all four essential ANC services. Binary logistic regression was employed to examine the likelihood of receiving good-quality ANC across various sociodemographic variables.

RESULTS

Only 6.2% of women received good-quality ANC. Factors significantly associated with receiving good-quality ANC included woman's secondary (AOR:1.87, 95%CI: 1.33-2.63) and higher education levels (AOR: 1.75, 95%CI: 1.01-3.03), household head's higher education level (AOR:1.63, 95%CI: 1.11-2.40), and wealth status (1.71, 2.26, 1.92, and 1.97 higher odds of receiving good-quality ANC for 2nd, 3rd, 4th, and 5th as compared to 1st quintiles of wealth, respectively).

CONCLUSION

The low utilization of good-quality ANC among women in Afghanistan, particularly among those at lower wealth status, with low education levels, underscores the need for targeted interventions to improve access and utilization of antenatal care services.

Inequality in Afghanistan in the use of prenatal healthcare services according to the sex of newborns

Objective

The association between the sex of newborns and the utilization of prenatal healthcare services during pregnancy and childbirth has not been thoroughly studied. This study investigated the association between the sex of newborns and the extent to which women used prenatal healthcare services in Afghanistan.

Materials and Methods

This study used data obtained from a nationally representative demographic and health survey. The participants in this analysis were women who had given birth in the last five years (n=19,126). Four indicators related to prenatal healthcare utilization were used: (1) number of antenatal care (ANC) visits, (2) number of ANC services provided by skilled professionals, (3) quality of ANC services, and (4) institutional delivery. Multivariate linear and logistic regression models were employed to examine the association between the sex of newborns and the use of prenatal healthcare services after adjusting for sociodemographic and decision-making autonomy variables.

Results

There was a significant association between the sex of newborns and use of prenatal healthcare services. Women with female newborns used ANC services fewer times (β =-0.10, 95% CI: -0.17, -0.03), used ANC services provided by skilled professionals fewer times (β=-0.11, 95% CI: -0.18, -0.04), were less likely to receive high-quality ANC (adjusted odds ratio (AOR)=0.78, 95% confidence interval (CI): 0.67, 0.90), and were less likely to deliver their babies at health institutions (AOR=0.83, 95% CI: 0.77, 0.91) than those with male newborns, after adjusting for other variables.

Conclusion

The findings revealed a negative association between female newborns and the utilization of prenatal healthcare services among women of reproductive age in Afghanistan. It is important to pay attention to this issue and ensure that all women have equal access to healthcare services regardless of their newborn's sex.

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

Compliance towards WHO recommendations on antenatal care for a positive pregnancy experience: Timeliness and adequacy of antenatal care visit in Sub-Saharan African countries: Evidence from the most recent standard Demographic Health Survey data

BACKGROUND

Timely and adequate antenatal care (ANC) visits are known to reduce maternal mortality by 20%. Despite the World Health Organization updating its recommendations from four to eight antenatal care contacts, data reporting in the SSA region focused primarily on four visits, and evidence on the timing and adequacy of ANC based on the current recommendation was limited. Hence, this study aimed at assessing the level of timely and adequate ANC visits and their determinants in the 18 Sub-Saharan African countries with the most recent DHS report (2016-2021).

METHODS

The data for this study were pooled from the most recent standardized Demographic and Health Survey data of sub-Saharan African countries from 2016-2021. A total of 171,183 (with a weighted frequency of 171,488) women were included and analyzed by using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was run to determine the effects of each predictor on the receipt of timely and adequate ANC. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The receipt of timely and adequate antenatal care visits was 41.2% (95% CI: 40.9, 41.4) and 10.4% (95% CI: 9.9, 10.2), respectively. Wontedness of pregnancy [AOR = 1.18; 95% CI: 1.13, 1.24], being 1st birth order [AOR = 1.48; 95% CI: 1.41, 2.54], having a mobile phone [AOR = 1.49; 95% CI: 1.26, 2.32], and enrolled in Health insurance schemes [AOR = 2.03; 95% CI: 1.95, 2.42] were significantly associated with early initiation of ANC. Living in a lower community poverty level[AOR = 2.23; 95% CI: 1.90,2.66], being in the richest wealth quintile [AOR = 1.49; 95% CI: 1.36, 1.62], higher educational level [AOR = 3.63; 95% CI: 3.33, 3.96], the timing of ANC visit [AOR = 4.26; 95% CI: 4.08, 4.44], being autonomous in decision making [AOR = 2.29; 95% CI: 1.83, 2.54] and having a mobile phone [AOR = 1.89; 95% CI: 1.76, 2.52] were identified as significant predictors of adequate ANC uptake.

CONCLUSION

The findings revealed a low coverage of timely and adequate ANC visits in SSA countries. Governments and healthcare managers in sub-Saharan African countries should leverage their efforts to prioritize and implement activities and interventions that increase women's autonomy, and economic capability, to improve their health-seeking behavior during pregnancy. More commitment is needed from governments to increase mobile phone distribution across countries, and then work on integrating mHealth into their health system. Finally, efforts should be made to increase the coverage of health insurance schemes enrolment for the citizens.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Development and evaluation of a culturally adapted digital-platform integrated multifaceted intervention to promote the utilization of maternal healthcare services: a single-arm pilot study

BACKGROUND

The utilization of hospital delivery and antenatal care (ANC) is essential for improving maternal and newborn outcomes. However, social and cultural barriers in underdeveloped rural areas hindered maternal care utilization. This study aims to design and evaluate the effectiveness of a culturally adapted digital-platform intervention to promote maternal care utilization among women in ethnic minority communities in China.

METHODS

From January 1st, 2020, to December 31st, 2021, all pregnant women in Mianshan town, Liangshan Autonomous Prefecture, were invited to participate in the intervention. The multifaceted intervention included participatory and cultural-tailored health education on a popular social media platform, transportation subsidies, and capacity building and economic incentives for healthcare providers. The effectiveness of the intervention was evaluated by comparing two groups: mothers who gave live birth before the intervention (January 1st to December 31st, 2019) and mothers whose entire pregnancy period was covered by the intervention. The primary outcomes were the rate of hospital delivery and ANC utilization. Data on pregnant women were retrospectively collected through telephone surveys and the maternal and newborn's health monitoring system.

RESULTS

A total of 237 intervention sample and 138 pre-intervention sample were included. The intervention group demonstrated significantly higher rates of hospital delivery (97.5% vs. 87.7%, p < 0.001), timely initiation of ANC (73.0% vs. 62.3%, p = 0.031), and timely completion of five-time ANC visits (37.1% vs.4.3%, p < 0.001) compared to the pre-intervention group. The intervention group was more likely to utilize hospital delivery (OR = 9.26, 95%CI [2.83-30.24], p < 0.001) and ANC, including timely initiation of ANC (OR = 2.18, 95%CI [1.31-3.62], p = 0.003), completion of five ANC visits (OR = 1.72, 95%CI [1.05-2.83], p = 0.032), and timely completion of five ANC visits (OR = 15.12, 95%CI [6.24-36.64], p < 0.001).

CONCLUSIONS

The culturally adapted digital-platform integrated multifaceted intervention effectively promoted the utilization of hospital delivery, timely initiation of ANC, and completion of ANC visits in the Yi ethnic community in China. This study provides valuable insights for future interventions targeting maternal healthcare services in underdeveloped ethnic minority communities worldwide.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300073219. Registered 4 July 2023 - Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=199202 .

Antenatal care utilization and its associated factors in Somalia: a cross-sectional study

BACKGROUND

WHO recommends attending minimum four ANC consultations during pregnancy to ensure early detection of complications. The objective of this study was to quantify ANC attendance and factors associated with it.

METHODS

Participants were randomly selected using the WHO Cluster survey methodology in Southern and Central Somalia. A paper-print questionnaire was used to collect all data. Outcomes of interest were: access to at least one ANC consultation, completion of at least four ANC consultations, initiation of breastfeeding and place of delivery, while exposures included factors related to the latest pregnancy and demographic characteristics. Associations were assessed through logistic regression.

RESULTS

Seven hundred ninety-two women answered the questionnaire; 85% attended at least one and 23% at least four ANC consultations, 95% started breastfeeding and 51% had an institutional delivery. Encouragement to attend ANC increased the odds of attending at least one consultation (aOR = 8.22, 95%CI 4.36-15.49), while negative attitude of husband or family decreased the odds (aOR = 0.33, 95%CI 0.16-0.69). Knowing there is a midwife increased the odds of at least four visits (aOR = 1.87, 95%CI 1.03-3.41). Attending at least four consultations increased the odds of delivering in a health structure (aOR = 1.50, 95%CI 1.01-2.24), and attending at least one consultation was associated with higher odds of initiating breastfeeding (aOR = 2.69, 95%CI 1.07-6.74).

CONCLUSIONS

Family has a strong influence in women's ANC attendance, which increases the likelihood of institutional delivery and initiating breastfeeding. Women and families need to have access to information about benefits and availability of services; potential solutions can include health education and outreach interventions.

Predicting maternal healthcare seeking behaviour in Afghanistan: exploring sociodemographic factors and women's knowledge of severity of illness

BACKGROUND

Little is known whether women's knowledge of perceived severity of illness and sociodemographic characteristics of women influence healthcare seeking behavior for maternal health services in Afghanistan. The aim of this study was to address this knowledge gap.

METHODS

Data were used from the Afghanistan Health Survey 2018. Women's knowledge in terms of danger signs or symptoms during pregnancy was assessed. The signs or symptoms were bleeding, swelling of the body, headache, fever, or any other danger sign or symptom (e.g., high blood pressure). A categorical variable of knowledge score was created. The outcome variables were defined as ≥ 4 ANC vs. 0-3 ANC; ≥ 4 PNC vs. 0-3 PNC visits; institutional vs. non-institutional deliveries. A multivariable generalized linear model (GLM) was used.

RESULTS

Data were used from 9,190 ever-married women, aged 13-49 years, who gave birth in the past two years. It was found that 56%, 22% and 2% of women sought healthcare for institutional delivery, ≥ 4 ANC, ≥ 4 PNC visits, respectively, and that women's knowledge is a strong predictor of healthcare seeking [odds ratio (OR)1.77(1.54-2.05), 2.28(1.99-2.61), and 2.78 (2.34-3.32) on knowledge of 1, 2, and 3-5 signs or symptoms, respectively, in women with ≥ 4 ANC visits when compared with women who knew none of the signs or symptoms. In women with ≥ 4 PNC visits, it was 1.80(1.12-2.90), 2.22(1.42-3.48), and 3.33(2.00-5.54), respectively. In women with institutional deliveries, it was 1.49(1.32-1.68), 2.02(1.78-2.28), and 2.34(1.95-2.79), respectively. Other strong predictors were women's education level, multiparity, residential areas (urban vs. rural), socioeconomic status, access to mass media (radio, TV, the internet), access of women to health workers for birth, and decision-making for women where to deliver. However, age of women was not a strong predictor.

CONCLUSION

Our findings suggest that pregnant women's healthcare seeking behaviour is influenced by women's knowledge of danger signs and symptoms during pregnancy, women's education, socioeconomic status, access to media, husband's, in-laws' and relatives' decisions, residential area, multiparity, and access to health workers. The findings have implications for promoting safe motherhood and childbirth practices through improving women's knowledge, education, and social status.