Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study

Beyond averages: dissecting urban-rural disparities in skilled antenatal care utilization in Bangladesh - a conway-maxwell-poisson regression analysis

BACKGROUND

Taking a sufficient number of skilled antenatal care (SANC) visits is incontrovertibly connected to safe motherhood. This study aims to shed light on the prevalence and potential factors associated with disparities in the SANC taking behavior of pregnant mothers in rural and urban Bangladesh.

METHODS

For this purpose, a nationally representative secondary dataset from the Bangladesh Demographic and Health Survey (BDHS, 2017-18) has been considered. The information regarding the last birth of mothers who delivered within three years preceding the survey has been analyzed. We have applied the Conway-Maxwell-Poisson regression model (CMPRM) to deal with the overdispersion in skilled ANC count data, as this model shows the least AIC compared to the classical negative-binomial regression model (NBRM) and the generalized Poisson regression model (GPRM).

RESULTS

Significant disparity (p-value < 0.001) has been observed in the mean number of SANC taken by rural (3.17) and urban (4.52) women. The analysis revealed that covariates have significantly different effects on SANC visits in rural areas compared to urban areas. For instance, women aged 35 and above in rural settings exhibited a 37% higher incidence rate of SANC visits (IRR = 1.37) compared to those under 20. Educational attainment had a pronounced impact, with rural women showing a 39% (IRR = 1.39) increase in SANC visits for primary education, 57% (IRR = 1.57) for secondary education, and 64% (IRR = 1.64) for higher education, compared to uneducated women. In contrast, in urban areas, higher education resulted in only a 35% (IRR = 1.35) increase.

CONCLUSION

Our findings from this study indicate that the concerned authority should come forward, and policymakers should emphasize various factors that are mainly responsible for the noteworthy different SANC status of pregnant women living in rural and urban areas in Bangladesh. Doing so, it can be hoped that the required number of ANC visits (eight or more) in both types of residences in Bangladesh, recommended by the World Health Organization (WHO), will be satisfied to ensure safer motherhood.

Inequalities in utilization of maternal health services in Ethiopia: evidence from the PMA Ethiopia longitudinal survey

Background

Previous studies documented the existence of substantial inequalities in the utilization of maternal health services across different population subgroups in Ethiopia. Regularly monitoring the state of inequality could enhance efforts to address health inequality in the utilization of maternal health services. Therefore, this study aimed to measure the level of inequalities in the utilization of maternal health services in Ethiopia.

Method

The study used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) dataset. Longitudinal data was collected from a weighted sample of 1966 postpartum women using multistage stratified cluster sampling techniques between November 2021 to October 2022. We assessed inequality in maternal health services using three indicators: antenatal care four (ANC), skilled birth attendants (SBA), and postnatal care (PNC). Age, economic status, education level, place of residence, and subnational regions were used as dimensions for measuring inequality. The analysis was conducted using Health Equity Assessment Toolkit Plus (HEAT Plus) software. We computed the summary measure of health inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF).

Result

The simple summary measures of inequality difference (D) reported a high level of inequality in the utilization of maternal health services in ANC four, SBA, and PNC across economic, education, residence, and subnational regions. The difference (D) in maternal health service utilization between advantaged and disadvantaged population groups exceeded 20 percentage points in all four dimensions of inequality for the three maternal health indicators. Similarly, the complex summary measures of inequality (PAR and PAF) also showed high levels of inequality in the utilization of ANC four, SBA, and PNC across all four dimensions of inequality. However, there was no age-related inequality in the use of maternal health services.

Conclusion

A high level of socioeconomic and geographic area related inequality was observed in the utilization of ANC four, SBA, and PNC services in Ethiopia. Women from socioeconomically disadvantaged subgroups and women from disadvantaged geographic areas significantly lagged behind in the utilization of maternal health services. Therefore, implementing targeted interventions for the most disadvantaged groups can help to reduce inequality in accessing maternal health services.

Trends in Coverage and Content of Maternal and Neonatal Care in Bamako, Mali

Coverage levels of maternal and neonatal health services in Mali's major cities vary due to the combined effect of several factors, including poverty and migration to urban centers. This worsened from 2012 due to the security crisis. We conducted an analysis of the trends and differences in several indicators of maternal and neonatal care coverage in Bamako using secondary data from Mali's Demographic and Health Surveys from 2001 to 2018. Our results highlighted differential access to antenatal and childbirth care for non-poor and non-migrant women compared to their counterparts categorized as poor and migrant. The gaps were much larger depending on migration status (i.e., number of years since resettling in Bamako) and even tended to increase over time. This was particularly the case regarding the number of antenatal visits (ANC 4+), with differences according to poverty level at 7 percentage points in 2001 and 8.3 percentage points in 2018. Migration status showed even larger gaps to the disadvantage of migrant women of 13.4 percentage points (2006) and 24.4 percentage points (2018). There is a higher proportion of cesarean section among non-poor women. The results suggested an opposite pattern for postnatal care of newborns, with a difference of 6.8 percentage points of coverage in favor of the poor in 2018. The high coverage of maternal and newborn health interventions in Bamako city conceals intra-urban disparities to the detriment of poor migrant women and those who recently migrated to the city, partly due to the conflicts and security issues. A redefinition of health programs to include such targets would be desirable from an equity perspective.

Why "free maternal healthcare" is not entirely free in Ghana: a qualitative exploration of the role of street-level bureaucratic power

BACKGROUND

Ghana introduced a free maternal healthcare policy within its National Health Insurance Scheme (NHIS) in 2008 to remove financial barriers to accessing maternal health services. Despite this policy, evidence suggests that women incur substantial out-of-pocket (OOP) payments for maternal health care. This study explores the underlying reasons for these persistent out-of-pocket payments within the context of Ghana's free maternal healthcare policy.

METHODS

Cross-sectional qualitative data were collected through interviews with a purposive sample of 14 mothers and 8 healthcare providers/administrators in two regions of Ghana between May and September 2022. All interviews were audio-recorded, transcribed and imported into the NVivo 14.0 software for analysis. An iteratively developed codebook guided the coding process. Our thematic data analysis followed the Attride-Sterling framework for network analysis, identifying basic, organising themes and global themes.

RESULTS

We found that health systems and demand-side factors are responsible for the persistence of OOP payments despite the existence of the free maternal healthcare policy in Ghana. Reasons for these payments arose from health systems factors, particularly, NHIS structural issues - delayed and insufficient reimbursements, inadequate NHIS benefit coverage, stockouts and supply chain challenges and demand-side factors - mothers' lack of education about the NHIS benefit package, and passing of cost onto patients. Due to structural and system level challenges, healthcare providers, exercising their street-level bureaucratic power, have partly repackaged the policy, enabling the persistence of out-of-pocket payments for maternal healthcare.

CONCLUSIONS

Urgent measures are required to address the structural and administrative issues confronting Ghana's free maternal health policy; otherwise, Ghana may not achieve the sustainable development goals targets on maternal and child health.

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Healthcare utilization in Ghana: Insights from the 2017 Ghana Living Standard Survey

INTRODUCTION

The persistence of healthcare utilization disparities in Ghana despite several policy efforts highlights the urgency of understanding its determinants to enhance equitable health access. We sought to examine the determinants of healthcare utilization in Ghana.

METHODS

We used the 2017 Ghana Living Standard Survey (GLSS) data. This was a cross-sectional design, which employed a stratified two-stage random sampling technique. We analyzed data involving 8,298 respondents with information on visits to healthcare facilities for services on account of illness or injury two weeks prior to the survey. Pearson's chi-squared test was used to assess the distribution of healthcare utilization across background characteristics. Further, we used multivariable Poisson regression model with robust standard error to identify factors independently associated with healthcare utilization.

RESULTS

Among the 8,298, the median age was 24 years (interquartile range = 7-47), 45% were males, and 45% had no education. About 42% of respondents utilized health services during an episode of illness or injury. Age, sex, educational level, marital status, wealth quintile, health insurance and severity of illness/injury were independently associated with healthcare utilization. Healthcare utilization increased significantly with wealth quintiles-those in the highest wealth quintiles had about 22% increased utilization compared to those in the lowest wealth quintiles (aPR = 1.22; 95%CI = 1.13-1.32) while it was about 77% higher among those who had valid health insurance compared to those without (aPR = 1.77; 95% CI = 1.68-1.86). Regarding severity of illness or injury, those with severe conditions were about 65% more likely to utilize healthcare services compared to those with acute conditions (aPR = 1.65; 95% CI = 1.53-1.78).

CONCLUSION

Our study underscores the importance of socio-economic factors and health insurance in healthcare utilization in Ghana. Addressing these can pave the way for more equitable access to healthcare services across all segments of the population.

Strengthening caesarean birth: Sub-Saharan Africa health system evaluation: Scoping review

BACKGROUND

 Promoting safe caesarean birth (CB) is a challenge in sub-Saharan Africa (SSA) where maternal and neonatal mortality rates are high due to inadequate maternal health services. Although the CB rate in SSA is lower than the World Health Organization (WHO) recommendation, it is often associated with high maternal and neonatal mortality.

AIM

 The aim of this scoping review was to report on the extent to which SSA health systems deliver safe CB.

METHODS

 A systematic search across various databases identified 53 relevant studies, comprising 30 quantitative, 10 qualitative and 16 mixed methods studies.

RESULTS

 These studies focused on clinical protocols, training, availability, accreditation, staff credentialing, hospital supervision, support infrastructure, risk factors, surgical interventions and complications related to maternal mortality and stillbirth. CB rates in SSA varied significantly, ranging from less than 1% to a high rate of 29.7%. Both very low as well as high rates contributed to significant maternal and neonatal morbidity. Factors influencing maternal and perinatal mortality include poor referral systems, inadequate healthcare facilities, poor quality of CBs, inequalities in access to maternity care and affordable CB intervention.

CONCLUSION

 The inadequate distribution of healthcare facilities, and limited access to emergency obstetric care impacted the quality of CBs. Early access to quality maternity services with skilled providers is recommended to improve CB safety.Contributions: This scoping review contributes to the body of knowledge motivating for the prioritization of maternal service across SSA.

Barriers to healthcare utilization among married women in Afghanistan: the role of asset ownership and women's autonomy

Women face multiple socio-economic, cultural, contextual, and perceived barriers in health service utilization. Moreover, poor autonomy and financial constraints act as crucial factors to their healthcare accessibility. Therefore, the objective of the present study is to study the association between health care utilization barriers and women empowerment, including asset ownership among currently married women in Afghanistan. Data of 28,661 currently married women from Afghanistan demographic health survey (2015) was used to carry out this study. Barriers to access healthcare were computed based on problems related to permission, money, distance, and companionship, whereas women empowerment and asset ownership were computed as potential covariates along with other socio-economic risk factors. Bivariate and logistic analysis was carried out to study the association and odds of explanatory variables. Our results confirm the significant and strong association between the barriers to access healthcare and various explanatory variables. Women having any decision-making autonomy are less likely to face any odds [(AOR = 0.56, p < 0.001), CI: 0.51-0.61] among the currently married women than those who don't have any decision-making authority. Similarly, women who justify their beating for some specific reasons face the greater difficulty of accessing health care [(AOR = 1.76, p < 0.001), CI: 1.61-1.93]. In terms of asset ownership, women having any asset ownership (land or household) are less likely to face any barriers in health services utilization given the lower odds [(AOR = 0.91, p < 0.001), CI: 0.90-0.98]. Accessing maternal health is a crucial policy challenge in Afghanistan. A substantial proportion of women face barriers related to approval, money, distance, and companionship while accessing the health services utilization in Afghanistan. Similarly, women empowerment and asset ownership are significantly associated with health service accessibility. This paper therefore suggests for some policy interventions to strengthen the healthcare needs of women and ensure healthcare accessibility by scaling down these potential barriers like poor autonomy, asset ownership and domestic violence.

Regional disparities in antenatal care utilization among pregnant women and its determinants in Ethiopia

Background

Antenatal care primarily focuses on health care checkups, the provision of advice on healthy behaviors, and the delivery of psychological, social, and emotional support for women with pregnancy. The national target set by the Ethiopian government is to achieve 95% of at least four ANC visits. Nevertheless, 43.11% of women had four or more checkups, according to the 2019 Ethiopian Demographic and Health Survey. Despite this achievement, antenatal care visits differ significantly between Ethiopian regions. Consequently, the purpose of this study was to assess regional disparities in pregnant women's utilization of antenatal care and its determinants in Ethiopia.

Methods

We have used 2019 intermediate Ethiopian Demographic and Health Survey data for analysis. The analysis comprised a total of 3,917 weighted women age 15-49 who had a live birth in the 5 years preceding the survey. Poisson regression analysis was done using SAS software version 9.4. To show the strength and direction of the association, an incidence rate ratio with a 95% confidence interval was used. Variables with a p-value <0.05 were declared as significant factors associated with the number of ANC visits.

Results

In Ethiopia, the number of ANC visits differs between regions. With a mean of 4.74 (95% CI: 4.49, 4.99), Addis Ababa reported the highest percentage of ANC visits (82.7%), while the Somali Region reported the lowest percentage (11.3%) with a mean of 0.73 (95% CI: 0.57, 0.88). Maternal age, educational level, religion, household wealth index, place of delivery, and household size show significant associations with the number of antenatal care visits.

Conclusions

In Ethiopia, there is the highest regional disparity in the number of ANC visits. The number of ANC visits was influenced by the mother's age, education, religion, household wealth index, place of delivery, and household size. Regarding the ANC visits, there should be initiatives that address the demands of pastoralist and agro-pastoralist communities to increase ANC utilization. As with many other health outcomes, education and low socio-economic status were associated with low ANC visit but these are tied to the overall social development of a country and are not immediately amenable to public health interventions.

Interplay of sociodemographic factors and antenatal care attendance with free maternal care policy: a case study of Ghana

Introduction

The Free Maternal Care Policy (FMCP) was introduced in Ghana around 2008 as part of the government's efforts to improve maternal and child health outcomes in the country. The policy was aimed at increasing access to antenatal care (ANC) services and reducing financial barriers to antenatal healthcare utilisation. Despite the expected success of the FMCP, there is limited evidence regarding its impact on the frequency of ANC visits across different sociodemographic groups of women in Ghana. This study examined associations between sociodemographic and health-related factors and the frequency of ANC attendance while considering the implementation period of the FMCP in Ghana as a fundamental reference point.

Methods

This quantitative study used Ghana's Demographic and Health Survey datasets on pregnant women's ANC visits for 2003, 2008 and 2014 (N=15 408). Logistic regression and descriptive analyses were conducted using Stata/SE V.14.

Results

Findings showed a slight fluctuation in the level of ANC visits before and after the introduction of the FMCP in Ghana. This fluctuation may indicate that ANC service cost as a barrier to ANC visits may not be the only factor affecting ANC utilisation among pregnant women in Ghana. Our results showed that women's lack of autonomy to make health-related decisions affected their ANC service utilisation, particularly in 2008. In addition, we found that educational attainment, being wealthy and urban residency were also significantly associated with ANC service utilisation among pregnant women in Ghana, particularly, in 2003. Women's anaemic levels were significantly associated with their likelihood of attending ANC services in 2003 and 2014.

Conclusions

Our findings suggest that the FMCP may have had a discernible effect on the utilisation of ANC services in Ghana. However, other significant confounding factors may be influencing the ongoing use of ANC services in this setting.

Trend of sociodemographic and economic inequalities in the use of maternal health services in Lao People's Democratic Republic from 2006 to 2017: MICS data analysis

BACKGROUND

Maternal mortalities remain high in the Lao People's Democratic Republic (Lao PDR). Since 2012, to improve access to maternal health services for all women, the country implemented several policies and strategies including user fee removal interventions for childbirth-related care. However, it remains unclear whether inequalities in access to services have reduced in the post-2012 period compared to pre-2012. Our study compared the change in sociodemographic and economic inequalities in access to maternal health services between 2006 to 2011-12 and 2011-12 to 2017.

METHODS

We used the three most recent Lao Social Indicator Survey datasets conducted in 2006, 2011-12, and 2017 for this analysis. We assessed wealth, area of residence, ethnicity, educational attainment, and women's age-related inequalities in the use of at least one antenatal care (ANC) visit with skilled personnel, institutional delivery, and at least one facility-based postnatal care (PNC) visit by mothers. The magnitude of inequalities was measured using concentration curves, concentration indices (CIX), and equiplots.

RESULTS

The coverage of at least one ANC with skilled personnel increased the most between 2012 and 2017, by 37.1% in Hmong minority ethnic group women, 36.1% in women living in rural areas, 31.1%, and 28.4 in the poorest and poor, respectively. In the same period, institutional deliveries increased the most among women in the middle quintiles by 32.8%, the poor by 29.3%, and Hmong women by 30.2%. The most significant reduction in inequalities was related to area of residence between 2006 and 2012 while it was based on wealth quintiles in the period 2011-12 to 2017. Finally, in 2017, wealth-related inequalities in institutional delivery remained high, with a CIX of 0.193 which was the highest of all CIX values.

CONCLUSION

There was a significant decline in inequalities based on the area of residence in the use of maternal health services between 2006 and 2011-12 while between 2011-12 and 2017, the largest decrease was based on wealth quintiles. Policies and strategies implemented since 2011-12 might have been successful in improving access to maternal health services in Lao PDR. Meanwhile, more attention should be given to improving the uptake of facility-based PNC visits.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

BACKGROUND

Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.

METHODS

We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.

RESULTS

The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.

CONCLUSIONS

Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Three fourths of women of reproductive age in emerging regions of Ethiopia are facing problems in accessing health care

Providing adequate and equal access health care is a key goal towards universal health coverage (UHC), but women continue to confront considerable inequities in accessing healthcare, particularly in the emerging regions of Ethiopia. Therefore, we identified the contributing factors to the problems in accessing health care among women of reproductive age in emerging regions of Ethiopia. Data from the 2016 Ethiopia Demographic and Health Survey were used. A total of 4680 women in reproductive age were included in the final analysis and a multilevel mixed-effect binary logistic regression analysis was done to identify the contributing factors to the problems in accessing health care. In the final model, a p-value of less than 0.05 and adjusted odds ratio (AOR) with 95% confidence interval (CI) were used to declare statistically significant factors. We found that 71.0% (95% CI 69.64-72.24%) of women in reproductive age had problems in accessing health care. Unmarried women (AOR = 1.30 95% CI 1.06-1.59), uneducated (AOR = 2.21 95% CI 1.48-3.30) and attended primary school (AOR = 1.58 95% 1.07-2.32), rural resident (AOR = 2.16 95% CI 1.40-2.02), poor (AOR = 2.95 95% CI 2.25-3.86) and middle wealth status (AOR = 1.74 95% CI 1.27-2.40), women who gave two births (AOR = 1.29 95% CI: 1.02-1.64) and not working (AOR = 1.33 95% CI 1.06, - 1.68) and working in agriculture (AOR = 1.88 95% CI 1.35-2.61) were factors that contributed for the problems in accessing health care. A significant proportion of women of reproductive age in emerging regions of Ethiopia face challenges in accessing healthcare, which places the country far from achieving its UHC targets. This issue is particularly prominent among unmarried, poor and middle wealth status, uneducated, non-working, and rural women of reproductive age. The government should develop strategies to improve women's education, household wealth status, and occupational opportunities which would help to alleviate the barriers hindering healthcare access for women residing in emerging regions of Ethiopia.

Skilled birth care uptake among women from socially disadvantaged minorities in the Kambata-Tambaro Zone, Southern Ethiopia

Globally in 2019, it was reported that 295,000 women die during pregnancy and childbirth every year. In Ethiopia, skilled birth care service uptake was low. Thus, the study aimed to assess the magnitude of skilled birth care uptake, and associated factors among women from socially disadvantaged minorities in the Kambeta-Temabaro Zone, Southern Ethiopia. A multistage sampling procedure was employed to enroll 521 study participants. Data were entered using EPI-INFO and SPSS-21 for analysis. Bivariate and multivariate analysis was done and the degree of association was assessed using odds ratios with a 95% confidence interval and variables with p values <0.05 were declared statistically significant. The magnitude of skilled birth care service uptake among women from socially disadvantaged minorities was 19%. Maternal education, occupation, awareness of birth care, pregnancy plan, number of births, mothers' lifestyle, and social subordination were significantly associated with skilled birth care service uptake in the study area. Thus, awareness creation on skilled birth, improving access to education for women, increasing the employability of women, and conducting community forums to avoid social discrimination against minorities are highly recommended.

Skilled antenatal care services utilisation in sub-Saharan Africa: a pooled analysis of demographic and health surveys from 32 countries

BACKGROUND

Each day, an estimated 800 women die from preventable pregnancy and childbirth related complications, where 99% of these avoidable deaths happen in low-and middle-income countries. Skilled attendance during antenatal care (ANC) plays a role in reducing maternal and child mortality. However, the factors that predict the utilisation of skilled ANC services in sub-Saharan Africa (SSA) remains sparsely investigated. Therefore, we examined women's utilisation of skilled ANC services in SSA.

METHODS

The research used pooled data from the most recent Demographic and Health Surveys conducted in 32 countries in SSA between January 1, 2010, and December 31, 2019. Binary logistic regression was used to examine the predictors of skilled ANC services utilisation. The results are presented as crude and adjusted odds ratios (aOR) with 95% confidence interval (CI).

RESULTS

The prevalence of skilled ANC services utilisation in SSA was 76.0%, with the highest and lowest prevalence in Gambia (99.2%) and Burundi (8.4%), respectively. Lower odds of ANC from skilled providers was found among women aged 45-49 compared to those aged 20-24 (aOR = 0.86, CI = 0.79-0.94); widowed women compared to married women (aOR = 0.84, CI = 0.72-0.99); women who consider getting permission to visit the health facility as a big problem compared to those who consider that as not a big problem (aOR = 0.74, CI = 0.71-0.77); women who consider getting money needed for treatment as not a big problem compared to those who consider that as a big problem (aOR = 0.84, CI = 0.72-0.99); and women who consider distance to the health facility as a big problem compared to those who consider that as not a big problem (aOR = 0.75, CI = 0.72-0.77).

CONCLUSION

SSA has relatively high prevalence of skilled ANC services utilisation, however, there are substantial country-level disparities that need to be prioritised. Increasing maternal reproductive age being widowed and far distance to health facility were factors that predicted lower likelihood of skilled ANC services utilisation. There is, therefore, the need to intensify female formal education, invest in community-based healthcare facilities in rural areas and leverage on the media in advocating for skilled ANC services utilisation.

Factors associated with the choice of delivery place: A cross-sectional study in rural areas of Indonesia

Background

Developing countries, including Indonesia, commonly face maternal mortality as a public health concern, which needs special attention. Using maternal delivery services in health facilities may reduce maternal mortality. However, little is known about the general use of delivery services in health facilities in rural areas, Indonesia.

Objective

This study aimed to analyze determinants in choosing delivery places in rural areas of Indonesia.

Methods

A cross-sectional quantitative design with secondary data from the 2014 Indonesian Family Life Survey (IFLS) was used in this study. There were 2,389 mothers aged 15-49 years in rural areas were included. Data were analyzed using a logistic regression test.

Results

It was found that 67% of mothers gave birth in health facilities. Tertiary and secondary education levels, residence in Java and Bali regions, economic status, insurance ownership, and job status were significantly related to the choice of delivery place in health facilities. Tertiary education was the most dominant factor correlated with the use of delivery services in health facilities (p < 0.001; PR = 4.55; 95% CI = 3.751-5.542).

Conclusion

Education is the key factor associated with the choice of delivery place. Therefore, it is suggested that the government and healthcare workers, especially nurses and midwives, improve mothers' education and provide strategies to increase knowledge in choosing delivery services to enhance their health outcomes.

Inequalities in antenatal care in Ghana, 1998-2014

Background

In order to effectively and efficiently reduce maternal mortality and ensure optimal outcomes of pregnancy, equity is required in availability and provision of antenatal care. Thus, analysis of trends of socio-economic, demographic, cultural and geographical inequities is imperative to provide a holistic explanation for differences in availability, quality and utilization of antenatal care. We, therefore, investigated the trends in inequalities  in four or more antenatal care visits in Ghana, from 1998 to 2014.

Methods

We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software to analyse data from the 1998 to 2014 Ghana Demographic and Health Surveys. We disaggregated four or more antenatal care visits by four equality stratifiers: economic status, level of education, place of residence, and sub-national region. We measured inequality through summary measures: Difference, Population Attributable Risk (PAR), Ratio, and Population Attributable Fraction (PAF). A 95% uncertainty interval (UI) was constructed for point estimates to measure statistical significance.

Results

The Difference measure of 21.7% (95% UI; 15.2–28.2) and the PAF measure of 12.4% (95% UI 9.6–15.2) indicated significant absolute and relative economic-related disparities in four or more antenatal care visits favouring women in the highest wealth quintile. In the 2014 survey, the Difference measure of 13.1% (95% UI 8.2–19.1) and PAF of 6.5% (95% UI 4.2–8.7) indicate wide disparities in four or more antenatal care visits across education subgroups disfavouring non-educated women. The Difference measure of 9.3% (95% UI 5.8–12.9) and PAF of 5.8% (95% UI 4.7–6.8) suggest considerable relative and absolute urban–rural disparities in four or more antenatal care visits disfavouring rural women. The Difference measure of 20.6% (95% UI 8.8–32.2) and PAF of 7.1% (95% UI 2.9–11.4) in the 2014 survey show significant absolute and relative regional inequality in four or more antenatal care  visits, with significantly higher coverage among regions like Ashanti, compared to the Northern region.

Conclusions

We found a disproportionately lower uptake of four or more antenatal care visits among women who were poor, uneducated and living in rural areas and the Northern region. There is a need for policymakers to design interventions that will enable disadvantaged subpopulations to benefit from four or more antenatal care visits to meet the Sustainable Development Goal  3.1 that aims to reduce the maternal mortality ratio (MMR) to less than  70/100, 000 live births by 2030. Further studies are essential to understand the underlying factors for the  inequalities in antenatal care visits.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data

BACKGROUND

Maternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys.

METHODS

This was a cross-sectional study of 43,786 young women aged 15-24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05.

RESULTS

The prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80-2.29), SBA (95% CI = 4.67-7.20), and PNC (95% CI = 1.08-1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78-0.88; SBA: aOR = 0.82, 95% CI = 0.75-0.88; PNC: aOR = 0.88, 95% CI = 0.83-0.94).

CONCLUSION

While SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Maternity Continuum Care Completion and Its Associated Factors in Northwest Ethiopia

BACKGROUND

Continuum care is a basic package approach for women to receive essential services throughout pregnancy, childbirth, and postpartum, and it is critical for women and their infants' survival and well-being. Although it is an effective strategy for improving maternal and child health, it has not been implemented adequately in less developed countries, primarily in sub-Saharan Africa, including Ethiopia, where 55% of women have been dropped out from the continuum of care. Therefore, this study is aimed at assessing maternity continuum care completion and its associated factors within northwest Ethiopia, 2020.

MATERIALS AND METHODS

A community-based cross-sectional study design was considered among 504 women from March 10 to March 30, 2020, using pretested and structured questionnaires administered via face-to-face interviews. To select study participants, a simple random sampling technique was used. Data were coded, checked, and entered into EpiData software (V. 4.2), then transferred to SPSS (V. 25) for further analysis. A bivariable analysis with 95% CI was performed, and variables with P 0.25 during binary logistic regression were entered into a multivariable analysis to assess predictors' independent effect.

RESULTS

About 177 (37.6%) women completed maternal continuum care. Women with secondary education and above (AOR = 2.75, 95% CI 1.42-5.32), urban residence (AOR = 2.45, 95% CI 1.35-4.45), using ambulance transport (AOR = 3.96, 95% CI 2.19-7.19), mass media exposure (AOR = 3.64, 95% CI 2.02-6.56), and distance from health facilities (AOR = 3.22, 95% CI 1.84-5.63) showed significant positive associations with completion of maternity continuum care.

CONCLUSION

However, a higher proportion of mothers completed the continuum of maternity care in the district than Ethiopian Demographic and Health Survey 2016 (9.1%); further interventions are compulsory to reach the acceptable level. Hence, comprehensive awareness-raising, education, and promotion activities at the community and health facility levels and empowering women in health care and decision-making backing to expand the completion of maternity continuum of care are necessary.

Trend and decomposition analysis of risk factors of childbirths with no one present in Nigeria, 1990-2018

OBJECTIVES

To assess the trend and decompose the determinants of delivery with no one present (NOP) at birth with an in-depth subnational analysis in Nigeria.

DESIGN

Cross-sectional.

SETTING

Nigeria, with five waves of nationally representative data in 1990, 2003, 2008, 2013 and 2018.

PARTICIPANTS

Women with at least one childbirth within 5 years preceding each wave of data collection.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of interest is giving birth with NOP at delivery defined as childbirth assisted by no one. Data were analysed using Χ² and multivariate decomposition analyses at a 5% significance level.

RESULTS

The prevalence of having NOP at delivery was 15% over the studied period, ranges from 27% in 1990 to 11% in 2018. Overall, the prevalence of having NOP at delivery reduced significantly by 35% and 61% within 2003-2018 and 1990-2018, respectively (p<0.001). We found wide variations in NOP across the states in Nigeria. The highest NOP practice was in Zamfara (44%), Kano (40%) and Katsina (35%); while the practice was 0.1% in Bayelsa, 0.8% in Enugu, 0.9% in Osun and 1.1% in Imo state. The decomposition analysis of the changes in having NOP at delivery showed that 85.4% and 14.6% were due to differences in women's characteristics (endowment) and effects (coefficient), respectively. The most significant contributions to the changes were the decision-maker of healthcare utilisation (49%) and women educational status (24%). Only Gombe experienced a significant increase (p<0.05) in the level of having NOP between 2003 and 2018.

CONCLUSION

A long-term decreasing secular trend of NOP at delivery was found in Nigeria. NOP is more prevalent in the northern states than in the south. Achieving zero prevalence of NOP at delivery in Nigeria would require a special focus on healthcare utilisation, enhancing maternal education and healthcare utilisation decision-making power.

Adherence to COVID-19 preventive measures and associated factors among pregnant women in Ghana

OBJECTIVE

To assess adherence to COVID-19 preventive measures and its associated factors among pregnant women in Ghana.

METHODS

This was a cross-sectional study conducted in the Nabdam district, Ghana. Data were collected from 527 pregnant women randomly selected from antenatal care clinics from 16 healthcare facilities. Descriptive statistics were used to assess the prevalence of adherence to COVID-19 preventive measures. Multivariable logistic regression was used to estimate the factors associated with COVID-19 preventive measures, whilst adjusting for potential confounders.

RESULTS

The prevalence of wearing a face mask 18.0% (95% CI: 14.73%, 21.32%); of handwashing/hand sanitising 31.7% (95% CI: 27.70%, 35.67%), and of social distancing, 22.0% (95% CI: 18.46%, 25.56%). Multivariable logistic regression analysis revealed that knowledge of COVID-19 symptoms [Adjusted odds ratios (aOR): 2.86, 95% CI: 1.03, 7.89] and knowledge of COVID-19 transmission via contaminated surfaces/objects (aOR: 4.60, 95% CI: 1.23, 17.18) were associated with wearing a face mask. Pregnant women who knew that avoiding the touching of eyes, nose and mouth can prevent COVID-19 (aOR: 2.71, 95% CI: 1.01, 7.28), and knowledge of the virus being transmitted via contaminated objects/surfaces (aOR: 4.08, 95% CI: 1.42, 11.76), were associated with handwashing/hand sanitising. Knowledge of COVID-19 transmission via contaminated surfaces/objects (aOR: 15.27, 95% CI: 1.87, 124.43) was also associated with social distancing.

CONCLUSION

The findings of our study suggest that knowledge of COVID-19 symptoms, transmission and preventive measures may play an important role in the practice of preventive measures against COVID-19 among pregnant women.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

BACKGROUND

We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA).

METHODS

Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.

RESULTS

We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.

DISCUSSION

Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.

CONCLUSION

The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

Effects of combined decision-support and performance-based incentives on reported client satisfaction with maternal health services in primary facilities: A quasi-experimental study in the Upper East Region of Ghana

BACKGROUND

Computerized decision-support systems (CDSS) and performance-based incentives (PBIs) have potential to contribute to client satisfaction with health services. However, rigorous evidence is lacking on the effectiveness of these strategies in lower-income countries such as Ghana. This study aimed to determine the effect of a combined CDSS-PBI intervention on client satisfaction with maternal health services in primary facilities in the Upper East Region of Ghana.

METHODS

We employed a quasi-experimental controlled baseline and endline design to assess the effect of the combined interventions on client satisfaction with maternal health services, measured by quantitative pre/post-test client satisfaction survey. Our analysis used difference-in-difference logistic regression, controlling for potential covariates, to compare variables across intervention and comparison facilities at baseline and endline.

RESULTS

The combined CDSS-PBI intervention was associated with increased or unchanged client satisfaction with all maternal health services compared at endline. Antenatal client difference-in-difference of mean satisfaction scores were significant at endline for intervention (n = 378) and comparison (n = 362) healthcare facilities for overall satisfaction (DiD 0.058, p = 0.014), perception of providers' technical performance (DiD = 0.142; p = 0.006), client-provider interaction (DiD = 0.152; p = 0.001), and provider availability (DiD = 0.173; p = 0.001). Delivery client difference-in-difference of satisfaction scores were significant at endline for intervention (n = 318) and comparison (n = 240) healthcare facilities for overall satisfaction with delivery services (DiD = 0.072; p = 0.02) and client-provider interaction (DiD = 0.146; p = 0.02). However, mean overall satisfaction actually reduced slightly in intervention facilities, while DiD for technical performance and provider availability were not significant.

CONCLUSION

This combined CDSS-PBI intervention was associated with greater antenatal and delivery client satisfaction with some aspects of maternity services within two years of implementation. It could be expanded elsewhere if funds allow, though further research is still required to assess cost-effectiveness and long-term effects on client satisfaction and maternal health outcomes.

Reasons for the utilization of the services of traditional birth attendants during childbirth: A qualitative study in Northern Ghana

BACKGROUND

Skilled delivery reduces maternal and neonatal mortality. Ghana has put in place measures to reduce geographical and financial access to skilled delivery. Despite this, about 30% of deliveries still occur either at home or are conducted by traditional birth attendants. We, therefore, conducted this study to explore the reasons for the utilization of the services of traditional birth attendants despite the availability of health facilities.

METHOD

Using a phenomenology study design, we selected 31 women who delivered at facilities of four traditional birth attendants in the Northern region of Ghana. Purposive sampling was used to recruit only women who were resident at a place with a health facility for an in-depth interview. The interviews were recorded and transcribed into Microsoft word document. The transcripts were imported into NVivo 12 for thematic analyses.

RESULTS

The study found that quality of care was the main driver for traditional birth attendant delivery services. Poor attitude of midwives, maltreatment, and fear of caesarean section were barriers to skilled delivery. Community norms dictate that womanhood is linked to vaginal delivery and women who deliver through caesarean section do not receive the same level of respect. Traditional birth attendants were believed to be more experienced and understand the psychosocial needs of women during childbirth, unlike younger midwives. Furthermore, the inability of women to procure all items required for delivery at biomedical facilities emerged as push factors for traditional birth attendant delivery services. Preference for squatting position during childbirth and social support provided to mothers by traditional birth attendants are also an essential consideration for the use of their services.

CONCLUSION

The study concludes that health managers should go beyond reducing financial and geographical access to improving quality of care and the birth experience of women. These are necessary to complement the efforts at increasing the availability of health facilities and free delivery services.

Institutional delivery and associated factors among women in Ghana: findings from a 2017-2018 multiple indicator cluster survey

Background

Institutional delivery is essential in reducing maternal morbidity and mortality. We investigated the prevalence of institutional delivery and associated factors among women in Ghana.

Methods

National representative data from the 2017–2018 Ghana Multiple Indicator Cluster Survey was used for the analysis. The study included 3466 women, ages 15–49 y, who had a live birth in the last 2 y. Descriptive statistics were used to assess the prevalence of institutional delivery while multivariate logistic regression was used to assess the relationship between our variables of interest and institutional delivery.

Results

The prevalence of institutional delivery among women in Ghana was 77.89% (95% confidence interval [CI] 75.29 to 80.50). High-income households (adjusted odds ratio [aOR] 2.13 [95% CI 1.36 to 3.35]), attending antenatal care at least four times (aOR 2.37 [95% CI 1.54 to 3.65]) and knowing one's human immunodeficiency virus status (aOR 1.41 [95% CI 1.08 to 1.84]) were associated with higher odds of institutional delivery. Living in rural areas (aOR 0.43 [95% CI 0.27 to 0.67]), multiparity (aOR 0.59 [95% CI 0.41 to 0.85]) and no health insurance (aOR 0.57 [95% CI 0.44 to 0.74]) were associated with lower odds of institutional delivery.

Conclusions

The government of Ghana may need to focus on increasing health insurance utilization and antenatal care attendance in order to increase the coverage of institutional delivery.

Assessing the contextual effect of community in the utilization of postnatal care services in Ghana

BACKGROUND

Inequalities in the use of postnatal care services (PNC) in Ghana have been linked to poor maternal and neonatal health outcomes. This has ignited a genuine concern that PNC interventions with a focus on influencing solely individual-level risk factors do not achieve the desired results. This study aimed to examine the community-level effect on the utilization of postnatal care services. Specifically, the research explored clusters of non-utilization of PNC services as well as the effect of community-level factors on the utilization of PNC services, with the aim of informing equity-oriented policies and initiatives.

METHODS

The 2014 Ghana Demographic and Health Survey GDHS dataset was used in this study. Two statistical methods were used to analyze the data; spatial scan statistics were used to identify hotspots of non-use of PNC services and second two-level mixed logistic regression modeling was used to determine community-level factors associated with PNC services usage.

RESULTS

This study found non-use of PNC services to be especially concentrated among communities in the Northern region of Ghana. Also, the analyses revealed that community poverty level, as well as community secondary or higher education level, were significantly associated with the utilization of PNC services, independent of individual-level factors. In fact, this study identified that a woman dwelling in a community with a higher concentration of poor women is less likely to utilize of PNC services than those living in communities with a lower concentration of poor women (Adjusted odds ratio (AOR) = 0.60, 95%CI: 0.44-0.81). Finally, 24.0% of the heterogeneity in PNC services utilization was attributable to unobserved community variability.

CONCLUSION

The findings of this study indicate that community-level factors have an influence on women's health-seeking behavior. Community-level factors should be taken into consideration for planning and resource allocation purposes to reduce maternal health inequities. Also, high-risk communities of non-use of obstetric services were identified in this study which highlights the need to formulate community-specific strategies that can substantially shift post-natal use in a direction leading to universal coverage.

The shared experiences of insured members and the uninsured in health care access and utilization under Ghana's national health insurance scheme: Evidence from the Hohoe Municipality

BACKGROUND

The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 to remove financial barriers and to promote equitable access to health care services. Post implementation has been characterized by increases in access and utilization of services among the insured. The uninsured have been less likely to utilize services due to unaffordability of health care costs. In this study, we explored the experiences of the insured members of the NHIS, the uninsured and health professionals in accessing and utilizing health care services under the NHIS in the Hohoe Municipality of Ghana.

METHODS

Qualitative in-depth interviews were held with twenty-five NHIS insured, twenty-five uninsured, and five health care professionals, who were randomly sampled from the Hohoe Municipality to collect data for this study. Data was analyzed using thematic analysis.

RESULTS

Participants identified both enablers or motivating factors and barriers to health care services of the insured and uninsured. The major factors motivating members to access and use health care services were illness severity and symptom persistence. On the other hand, barriers identified included perceived poor service quality and lack of health insurance among the insured and uninsured respectively. Other barriers participants identified included financial constraints, poor attitudes of service providers, and prolonged waiting time. However, the level of care received were reportedly about the same among the insured and uninsured with access to quality health care much dependent on ability to pay, which favors the rich and thereby creating inequity in accessing the needed quality care services.

CONCLUSION

The implication of the financial barriers to health care access identified is that the poor and uninsured still suffer from health care access challenges, which questions the efficiency and core goal of the NHIS in removing financial barrier to health care access. This has the potential of undermining Ghana's ability to meet the Sustainable Development Goal 3.8 of universal health coverage by the year 2030.

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

Twenty-five years ago, the International Conference on Population and Development highlighted the need to address sexual and reproductive health (SRH) rights on a global scale. The sub-Saharan Africa region continues to have the highest levels of maternal mortality and HIV, primarily affecting the most vulnerable populations. Recognising the critical role of policy in understanding population health, we conducted a systematic review of original primary research which examined the relationships between equity-focused legislation and policy and the utilisation of SRH services by vulnerable populations in sub-Saharan Africa. We searched nine bibliographic databases for relevant articles published between 1994 and 2019. Thirty-two studies, conducted in 14 sub-Saharan African countries, met the inclusion criteria. They focused on maternal health service utilisation, either through specific fee reduction/removal policies, or through healthcare reforms and insurance schemes to increase SRH service utilisation. Findings across most of the studies showed that health-related legislation and policy promoted an increase in service utilisation, over time, especially for antenatal care, skilled birth attendance and facility-based delivery. However, social health inequalities persisted among subgroups of women. Neither the reviewed studies nor the policies specifically addressed youth, people living with HIV and people with disabilities. In the era of the sustainable development goals, addressing health inequities in the context of social determinants of health becomes unavoidable. Systematic and rigorous quantitative and qualitative research, including longitudinal policy evaluation, is required to understand the complex relationships between policy addressing upstream social determinants of health and health service utilisation.

Healthcare Utilisation of Moluccans in the Netherlands: Equal Care for Equal Need after 60 Years of Residence in the Host Country?

Background: In many countries, recent migrants have difficulties using healthcare to the same extent as host populations. It is uncertain whether these differences persist for long-settled migrants. This study examined healthcare utilisation of Moluccans in 2012, more than 60 years after they migrated from Indonesia to the Netherlands. Methods: A survey was held among 715 Moluccans and 3417 Dutch persons. Differences in healthcare utilisation were assessed using regression analyses adjusting for age, gender, indicators of health, religious affiliation, and education. Results: Moluccans had lower rates of healthcare use, including visits to the general practitioner (odds ratio (OR) = 0.67), outpatient medical specialist (OR = 0.50), dentist (OR = 0.65), and physiotherapist (OR = 0.56), as well as the use of paid housekeeping services (OR = 0.37). Among those who visited a healthcare service, no difference was found between Moluccans and Dutch in the frequency of visits, except for physiotherapist visits (rate ratio (RR) = 0.51). For the risk of hospitalisation, no difference was found; however, of those admitted to the hospital, the frequency of admission was lower among Moluccans than Dutch (RR = 0.74). Conclusions: Despite their long residence in the host country, equal utilisation of healthcare services has not been achieved for Moluccans in the Netherlands. Demand-based factors (e.g., family networks, health beliefs, and use of traditional medicine) may contribute to the persistence of such differences and require further investigation.

Predictors of maternal mortality in Ghana: evidence from the 2017 GMHS Verbal Autopsy data

BACKGROUND

Maternal mortality remains a significant public health challenge in many low and middle-income countries, including Ghana. From Ghana's 2017 Maternal Health Survey verbal autopsy data, we examined the predictors of maternal mortality in Ghana.

METHODS

A total of 1240 deaths of women aged 15-49 were involved in the survey across all regions in Ghana. Binary and multivariate logistic regression analyses were employed; confidence level was set at 95%.

RESULTS

The results show that the prevalence of maternal death was 13.2% (164/1240). After adjusting for potential covariates, women aged 20-29 years (aOR = 4.270, 95%CI= 1.864 - 9.781, p=0.001), bled during labour/delivery (aOR= 0.241, 95%CI = 0.059 - 0.992, p=0.049), and those who used traditional/herbal medicines during pregnancy were more likely to die compared to non-users (aOR= 3.461, 95%CI = 1.651 - 7.258, p=0.001).

CONCLUSION

Our findings highlight the need to intensify maternal education regarding the value to be gained by increasing skilled healthcare during complications in pregnancy to allow effective management of complications during labour/delivery. Also, education for pregnant women and their families on possible adverse effects of using unapproved traditional/herbal medicines during pregnancy as well as a need to seek timely care before the onset of labour to allow healthcare providers ample opportunity to address labour and birth complications, is urgently required.

Trends and factors associated with the utilisation of antenatal care services during the Millennium Development Goals era in Tanzania

Background

A detailed understanding of trends, as well as what act as enablers and/or barriers to the utilisation of antenatal care (ANC) among Tanzanian women, is essential to policymakers and health practitioners to guide maternal health efforts. We investigated the trends and factors associated with ANC service use during the Millennium Development Goals (MDG) era in Tanzania between 1999 and 2016.

Methods

The study used the Tanzania Demographic and Health Survey (TDHS) data for the years 1999 (n = 2095), 2004–2005 (n = 5576), 2010 (n = 6903) and 2015–2016 (n = 5392). Multivariate multinomial logistic regression models were used to investigate the association between predisposing, enabling, need and community-level factors and frequency of ANC (1–3 and ≥ 4) visits in Tanzania.

Results

The proportion of women who made one to three ANC visits improved significantly from 26.4% in 1999 to 47.0% in 2016. The percentage of women who make four or more ANC visits declined from 71.1% in 1999 to 51.0% in 2016. Higher maternal education, belonging to wealthier households, being informally employed and listening to the radio were associated with four or more ANC visits. Women who did not desire pregnancy had a lower likelihood to attend four or more ANC visits. Women who had primary or higher education, those who resided in wealthier households and those who were informally employed were more likely to make between one and three ANC visits.

Conclusion

The study showed that there was an improvement in the proportion of Tanzanian women who made one to three ANC visits, but it also indicated a concurrent decrease in the prevalence of four or more ANC visits. Improving uptake of ANC among Tanzanian women is achievable if national health policies and programmes also focus on key amenable maternal factors of education, household wealth and employment.

Prevalence and Determinants of Rural-Urban Utilization of Skilled Delivery Services in Northern Ghana

BACKGROUND

There are wide differences in the uptake of skilled delivery services between urban and rural women in the northern region of Ghana. This study assessed the rural-urban differences in the prevalence of and factors associated with uptake of skilled delivery in the northern region of Ghana.

METHODS

The study population comprised postpartum women who had delivered within the last three months prior to the study. The dataset was analyzed using the chi-square test and multivariable logistic regression.

RESULTS

The odds of skilled birth attendance (SBA) adjusted for confounding variables in urban areas were higher compared with their rural counterparts (AOR = 1.59; CI: 1. 07-2.37; p=0.02). The determinants of skilled delivery were similar but of different levels and strength in rural and urban areas. The main drivers that explained the relatively high skilled delivery coverage in the urban areas were higher frequency of antenatal care (ANC) attendance, proximity (physical access) to health facility, and greater proportion of women attaining higher educational level of at least secondary school. Distance from health facility less than 4 km was the greatest independent contributor to the variance in skilled delivery in the urban areas, whereas frequency of ANC attendance was the greatest independent contributor in the rural areas.

CONCLUSIONS

This study identified underlying determinants accounting for rural-urban differences in skilled delivery, and covariate effect was more dominant than coefficient effect. Therefore, urban-rural differences in SBA outcomes were primarily due to differences in the levels of critical determinants rather than the nature of the determinants themselves. Therefore, improving skilled delivery outcomes in this study population and other similar settings will not require different policy frameworks and interventions in dealing with rural-urban disparities in SBA outcomes. However, context-specific tailored approaches and strategies including targeting mechanisms have to be designed differently to reduce the rural-urban differences.

Potential factors associated with institutional childbirth among women in rural villages of Lao People's Democratic Republic: a preliminary study

Background

The provision of quality health services has been a global priority to reduce neonatal and maternal deaths. In Lao People’s Democratic Republic (Lao PDR), the coverage of institutional childbirth stayed at a low level regardless of a sharp increase in the coverage of antenatal care (ANC) and fee exemption. The aim of the present study was to preliminary explore factors associated with increased institutional childbirth and the association between ANC attendance and maternal knowledge among women in rural villages of Lao PDR.

Methods

A secondary data analysis was conducted using data collected through a pilot survey in Sekong province in Lao PDR. The study participants were women with children under 5 years of age in villages within 10 km (km) from health centers staffed with skilled birth attendants. Data were collected via a face-to-face interview using a semi-structured questionnaire and were analysed using logistic regression models to estimate odds ratios (ORs) and their 95% confidence intervals (CIs) for having institutional childbirth in relation to potential factors.

Results

A total of 302 women, 203 (67.2%) of whom gave birth at a health facility. 277 (91.7%) attended ANC at least once. Sixty-nine women (22.9%) had received no formal education, 272 (90.1%) were of an ethnic minority, 174 (57.6%) were unwaged and 99 (32.8%) lived more than 6 km from the nearest health facility. 51 (16.6%) did not know about birth complications at interview. Institutional childbirth was negatively associated with a lack of maternal knowledge about birth complications (OR, 0.27; 95% Cl, 0.14–0.54) after adjusting for covariates. Although there were few women who did not received ANC, the results suggested ANC might not be associated with maternal knowledge about birth complications (OR, 1.87; 95% Cl, 0.43–8.12).

Conclusions

The present study suggests that maternal knowledge about birth complications is an important factor in increasing the institutional childbirth in rural villages of Lao PDR where majority of residents were ethnic minority. Improving quality of ANC and attitude among health care providers may be key to increasing health-seeking behavior. However, further research is needed to understand factors influencing choice of place of childbirth.

In search of universal health coverage: the hidden cost of family planning to women in Ghana

Objective

This study aims to estimate the cost of accessing FP services in Ghana. A cross-sectional design, involving quantitative methods were used to recruit 1194 women who accessed FP services in 336 primary health facilities, selected through a two-stage sampling. Descriptive statistics were used to estimate the cost, using STATA 13.

Results

The average age of the women was 29 ± 6.87. Most women had basic education. The sources of payment for FP services were self-finance, family and sponsorship. The average direct cost of accessing FP services was GHS 7.90 [US$ 1.76]. The cost of FP services was highest for consultation GHS 7.50 [US$ 1.67], Laboratory test/x-ray GHS 6.03 [US$ 1.34], Transportation GHS GHS5.50 [US$ 1.22], Contraceptive GHS 4.73 [US$ 1.05] and Client records Card GHS 3.30 [US$ 0.73]. The cost of FP services was higher for clients visiting private facilities, tertiary level as well as those in urban centers. Clients on average spent 54.21 min traveling at a distance of 3.49 km and wait averagely 18.11 min for each visit. Government stakeholders are encouraged to revise the existing maternal health policies, as well as increase the list of FP services within the exemption package of the NHIS policy.

Experiences of homeless women on maternity health service utilization and associated challenge in Aksum town, Northern Ethiopia

BACKGROUND

Homeless women are a highly vulnerable group for risks of pregnancy and childbirth-related complications. They may also face multiple challenges to access and utilize maternity healthcare services. This study was aimed to explore the experience of homeless women on maternity healthcare service utilization and associated challenges in Aksum Town, Northern Ethiopia.

METHODS

An exploratory qualitative study was employed using in-depth interviews among 22 study participants from February to March 2016. Purposive sampling was used to recruit 12 homeless mothers who gave birth when being homeless in the last 12 months and 10 healthcare providers as key informants. Data were captured using audio recorders and field notes and transcribed, translated verbatim and thematic analysis approach was facilitated using ATLAS.ti7 software.

RESULTS

The finding reveals that homeless women did not use any of the basic maternity health care services, namely antenatal care, skilled birth attendance, and postnatal care. Lack of permanent place and awareness, and fear of stigma and discrimination were some reasons hindering homeless women from using the services.

CONCLUSIONS

Even though maternity health service utilization is the most crucial intervention to reduce maternal and newborn deaths, this finding shows that maternity health service utilization among homeless women was limited. Socio-cultural, socioeconomic and healthcare-related factors contributed to the non-use of these services. Efforts should be made to address the challenges faced by homeless women to utilize maternity health services.

Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone

BACKGROUND

As a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services.

METHODS

We analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS.

RESULTS

There was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to - 0.002263 [95% CI (- 0.002322, - 0.002204)] in 2013. The change in concentration index for PNC reviews was from - 0.001732 [95% CI (- 0.001746, - 0.001718)] in 2008 to - 0.001771 [95% CI (- 0.001779, - 0.001763)] in 2013. All changes were significant (p value < 0.001).

CONCLUSION

The FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a "Health in all Policy" framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

Trends and projections of universal health coverage indicators in Ghana, 1995-2030: A national and subnational study

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9-3.5) and 0.4% (95%CrI: 0.2-0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1-1.3) and 0.2% (0.0-0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps.

Factors influencing the use of supervised delivery services in Garu-Tempane District, Ghana

Background

There is evidence that supervised delivery has the potential to improve birth outcomes for both women and newborns. However, not all women especially in low-income settings like Ghana use supervised delivery services during childbirth. The purpose of this study was to estimate the prevalence of supervised delivery and determine factors that influence use of supervised delivery services in a local district of Ghana.

Methods

A retrospective cross-sectional survey of 322 randomly sampled postpartum women who delivered between January and December 2016 in the Garu-Tempane District was conducted. Structured questionnaires were used to collect data. Descriptive, binary and multivariate logistic regression analysis techniques were used to analyse data.

Results

Although antenatal care attendance among respondents was very high 291(90.4%), prevalence of supervised birth was only 219(68%). More than a quarter 103(32%) of the postpartum women delivered their babies at home without skilled birth attendants. After controlling for possible confounders in multivariable logistic regression analyses, factors that strongly independently predicted supervised delivery were religion (p < 0.01), distance to health facility (p < 0.05), making at least 4 antenatal care visits (p < 0.01), national health insurance scheme registration (p < 0.01), satisfaction with services received during antenatal care (p < 0.01), need partner’s approval before delivering in health facility (p < 0.01), woman’s thoughts that her religious beliefs prohibited health facility delivery(p < 0.01), and woman’s belief that there are norms in her community that did not support health facility delivery (p < 0.01).

Conclusion

There is need for targeted interventions, including community mobilization and health education, and male partner involvement to help generate local demand for, and uptake of, supervised delivery services. Improvement in the quality of services in health facilities, including ensuring respect and dignity for service users, would also be essential.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2295-6) contains supplementary material, which is available to authorized users.

Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015-2017

OBJECTIVES

To assess variations by time of year and hospital in the uptake of influenza and pertussis vaccinations by pregnant women in Victoria; to identify factors associated with vaccination uptake.

DESIGN, SETTING

Retrospective analysis of data in the Victorian Perinatal Data Collection (VPDC), a population surveillance system for obstetric conditions, procedures, and pregnancy and birth outcomes.

PARTICIPANTS

Women whose pregnancies ended in a live or stillbirth during July 2015 - June 2017.

MAIN OUTCOME MEASURES

Influenza and pertussis vaccinations during pregnancy.

RESULTS

153 980 pregnancies in 67 hospitals ended during July 2015 - June 2017; 59 968 pregnant women (39.0%) were vaccinated against influenza and 98 583 (64.0%) against pertussis. Coverage varied by pregnancy end date, rising for influenza during winter and spring, but for pertussis rising continuously across the two years from 37.5% to 82.2%. Differences between hospitals in coverage were marked. Factors associated with vaccination included greater maternal age, primigravidity, early antenatal care, and GP-led care. The odds of vaccination were statistically significantly lower for women born overseas and those who smoked during pregnancy; the odds of vaccination were also lower for Aboriginal and Torres Strait Islander women.

CONCLUSIONS

Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable. Structural changes at the system level may improve maternal vaccination rates. Embedding the delivery of maternal vaccination programs in antenatal care pathways should be a priority.

Facility delivery and postnatal care services use among mothers who attended four or more antenatal care visits in Ethiopia: further analysis of the 2016 demographic and health survey

Background

Antenatal care provides the best opportunity to promote maternal and child health services use. But many Ethiopian mothers deliver at home and fail to attend postnatal care. Therefore, this study was done to identify factors associated with health facility delivery among mothers who attended four or more antenatal care visits. The study was also intended to identify factors associated with postnatal care service use among mothers who delivered at home after four or more antenatal care visits.

Methods

This study used the 2016 Ethiopian Demographic and Health Survey data. Two thousand four hundred fifteen women who attended four or more antenatal care visits were included to identify factors associated with health facility delivery after four or more antenatal care visits. Among them, 1055 mothers delivered at home. These women were included to identify factors associated with postnatal care service use. Stata 15.1 was used to analyze the data. Multivariable logistic regression model was fitted to identify associations between the outcome and predictor variables.

Results

Among women who had four or more antenatal care visits, 56% delivered at health facility. Mothers with secondary or higher level of education (AOR = 2.9; 95% CI = 1.6–5.3), urban residents (AOR = 3.4; 95% CI = 1.9–6.1), women with highest wealth quintile (AOR = 2.7; 95% CI = 1.5–4.8), and working women (AOR = 1.6; 95% CI = 1.2–2.3) had higher odds of delivering at health facilities. High birth order (AOR = 0.5; 95% CI = 0.3–0.7) was negatively associated with a lower likelihood of health facility delivery. Among women who delivered at home, only 8% received postnatal care within 42 days after delivery. Only the content of care received during antenatal care visits (AOR = 1.40; 95% CI = 1.1–1.8) was significantly associated with postnatal care attendance.

Conclusion

Women with lower socio-economic status had lower odds of giving birth at health facility even after attending antenatal care. The more antenatal care components a mother received, the higher her probability of delivering at health facility. Similarly, postnatal care attendance was higher among women who had received more antenatal care components.

Understanding factors influencing home delivery in the context of user-fee abolition in Northern Ghana: Evidence from 2014 DHS

User-fee exemption for skilled delivery services has been implemented in Ghana since 2003 as a way to address financial barriers to access. However, many women still deliver at home. Based on data from the 2014 Ghana Demographic and Health Survey, we estimated the prevalence of home delivery and determined the factors contributing to homebirths among a total of 622 women in the Northern region in the context of the user-fee exemption policy in Ghana. Binary and multivariate logistic regression analyses were employed. Results suggest home delivery prevalence of 59% (365/622). Traditional birth attendants attended majority of home deliveries (93.4%). After adjusting for potential confounders, making less than four antenatal care visits (aOR = 2.42; CI = 1.91-6.45; p = 0.001), being a practitioner of traditional African religion (aOR = 16.40; CI = 3.10-25.40; p = 0.000), being a Muslim (aOR 2.10; CI = 1.46-5.30; p = 0.042), not having a health insurance (aOR = 1.85; CI = 1.773-4.72; p = 0.016), living in a male-headed household (aOR = 2.07; CI = 1.02-4.53; p < 0.01), and being unexposed to media (aOR = 3.10; CI = 1.12-5.38; p = 0.021) significantly predicted home delivery. Our results suggest that unless interventions are implemented to address other health system factors like insurance coverage, and socio-cultural and religious beliefs that hinder uptake of skilled care, the full benefits of user-fee exemption may not be realized in Ghana.

Perceived barriers to maternal and newborn health services delivery: a qualitative study of health workers and community members in low and middle-income settings

OBJECTIVES

In considering explanations for poor maternal and newborn health outcomes, many investigations have focused on the decision-making patterns and actions of expectant mothers and families, as opposed to exploring the 'supply side' (health service provider) barriers. Thus, we examined the health system factors impacting on access to and delivery of quality maternal and newborn healthcare in rural settings.

DESIGN

A semistructured qualitative study using face-to-face in-depth interviews with health professionals, and focus group sessions with community members, in eight project sites in two districts of Upper West Region, Ghana, was employed. Participants were purposively selected to generate relevant data to help address the study objective. The survey was guided by WHO standard procedures and Ghana Health Ministry's operational work plan for maternal and newborn care.

SETTING

Nadowli-Kaleo and Daffiama-Bussie-Issa districts in Upper West Region, Ghana.

PARTICIPANTS

Two hundred and fifty-three participants were engaged in the study through convenient and purposive sampling: healthcare professionals (pharmacist, medical doctor, two district directors of health services, midwives, community health and enrolled nurses) (n=13) and community members comprising opinion leaders, youth leaders and adult non-pregnant women (n=240 in 24 units of focus groups).

RESULTS

Results show significant barriers affecting the quality and appropriateness of maternal and neonatal health services in the rural communities and the Nadowli District Hospital. The obstacles were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines and general limited capacities to provide care.

CONCLUSION

Implementation of the birth preparedness and complication readiness strategy is in its infancy at the health facility level in the study areas. Increasing the resources at the health provider level is essential to achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare.

Improving access to healthcare for women in Tanzania by addressing socioeconomic determinants and health insurance: a population-based cross-sectional survey

OBJECTIVE

This study was performed to explore the factors associated with accumulation of multiple problems in accessing healthcare among women in Tanzania as an example of a low-income country.

DESIGN

Population-based cross-sectional survey.

SETTING

Nationwide representative data for women of reproductive age obtained from the 2015-2016 Tanzania Demographic and Health Survey were analysed.

PRIMARY OUTCOME MEASURES

A composite variable, 'problems in accessing healthcare', with five (1-5) categories was created based on the number of problems reported: obtaining permission to go to the doctor, obtaining money to pay for advice or treatment, distance to a health facility and not wanting to go alone. Respondents who reported fewer or more problems placed in lower and higher categories, respectively.

RESULTS

A total of 13 266 women aged 15-49 years, with a median age (IQR) of 27 (20-36) years were interviewed and included in the analysis. About two-thirds (65.53%) of the respondents reported at least one of the four major problems in accessing healthcare. Furthermore, after controlling for other variables included in the final model, women without any type of health insurance, those belonging to the poorest class according to the wealth index, those who had not attended any type of formal education, those who were not employed for cash, each year of increasing age and those who were divorced, separated or widowed were associated with greater problems in accessing healthcare.

CONCLUSION

This study indicated the additive effects of barriers to healthcare in low-income countries such as Tanzania. Based on these results, improving uptake of health insurance and addressing social determinants of health are the first steps towards reducing women's problems associated with accessing healthcare.

Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa

BACKGROUND

Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region.

METHODS

We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use.

RESULTS

Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%).

CONCLUSIONS

Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology.

Are maternal healthcare services accessible to vulnerable group? A study among women with disabilities in rural Nepal

BACKGROUND

Studies report that vulnerable groups like people with disabilities have less access to healthcare. This study compares health service access between women with and without disabilities in general and explores the challenges encountered by women with disabilities in accessing maternal healthcare services during pregnancy.

METHODS

A mixed method study was conducted in Rupandehi district of Nepal implementing a cross-sectional survey among 354 women including 79 women with disabilities, supplemented by 43 in-depth interviews. Descriptive and bivariate statistical analysis of quantitative data using Pearson's Chi-square test for association was carried out, while qualitative data were analysed following the theme content analysis using a framework approach.

RESULTS

The vast majority of women from both groups, women with and without disabilities (71% vs 74%) reported that the nearest health facility from their location was more than 30 minutes walking distance (P>0.05). Half of the women with disabilities walked to health facilities for ANC check-ups. Over one-third of women without disabilities and a slightly lesser proportion of women with disabilities (29%) used a low-cost means of transport (rikshaw, bi/tri-cycles) (P>0.05). Distribution of health facilities found uneven and poorly linked with road transport facilities. None of the health facilities accommodated the needs of women with disabilities with accessible buildings and convenient opening time. The travel cost and the extra cost of services, staff shortage, often delayed and inadequate drug supplies were common problems for both women with and without disabilities. Unavailability of beds during delivery, insensitive providers with negative attitudes and abusive behaviour, inadequate knowledge and experience in providing services to the people with disabilities as well as unwelcoming health facility environment made services particularly inaccessible to women with disabilities.

CONCLUSION

Maternal healthcare services are not easily and equitably accessible to women with disabilities. To increase access to healthcare for this vulnerable group, improvements are needed in distribution and management of resources from transportation through service delivery, as well as improved provider knowledge and awareness of a human rights approach to disability and health.

Determinants of choice of skilled antenatal care service providers in Ghana: analysis of demographic and health survey

BACKGROUND

The International Safe Motherhood initiative provides a focus for programmes and research to improve maternal health in low - income countries. Antenatal care is one of the key pillars of the initiative. This study sought to examine the association between background characteristics and choice of skilled providers of antenatal care services in Ghana.

METHODS

The study used data from the six rounds of the Ghana Demographic and Health Survey (GDHS). Binary logistic regression models were applied to analyse the data.

RESULTS

Results show that the proportion of women who received antenatal care (ANC) services from skilled providers improved over the period. Also, women with secondary education (OR = 1.42, CI = 1.07-1.88), richest wealth status (OR = 5.10, CI = 2.28-11.85) were more likely to utilise antenatal care services from skilled providers. Whereas women from rural areas (OR = 0.55, CI = 0.41-0.74), with four births or more (OR = 0.55, CI = 0.36-0.85) and from the northern ethnic group were less likely to utilise antenatal care services from skilled providers.

CONCLUSION

Choice of skilled providers of antenatal care services were predicted by some predisposing factors including education, ethnicity, and ecological zone. Also enabling factors such as wealth status, residence and the need for care factor, parity predicted choice of skilled providers of antenatal care services. Women with secondary or higher education, those within richer and richest wealth status, those from forest zone are more likely to utilise the services of skilled providers during their antenatal care visits. Whereas women from rural areas, those with four births or more and those with the northern ethnic group were more likely to utilise ANC service from unskilled providers. The Ghana Health Service and Ministry of Health should encourage women in rural areas to utilise antenatal care services from skilled providers through social and behaviour change communication campaigns.

Do free caesarean section policies increase inequalities in Benin and Mali?

BACKGROUND

Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced.

METHODS

We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries.

RESULTS

We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present.

CONCLUSIONS

Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Inequities and their determinants in coverage of maternal health services in Burkina Faso

Background

Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso.

Methods

We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders.

Results

Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables.

Conclusion

Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.

WOMEN'S EDUCATION AND UTILIZATION OF MATERNAL HEALTH SERVICES IN AFRICA: A MULTI-COUNTRY AND SOCIOECONOMIC STATUS ANALYSIS

There is an abundant literature on the relationship between women's education and maternal and child outcomes, including antenatal and postnatal care, onset of antenatal care and skilled birth attendance. However, few studies have adopted the 'equity' lens, despite increasing evidence that inequities between rich and poor are increasing although maternal and child mortality is declining. This study examined the differential effects of women's education within different socioeconomic strata in Africa. The most recent Demographic and Health Surveys (DHS) conducted in the Democratic Republic of the Congo, Egypt, Ghana, Nigeria and Zimbabwe were used. In each country, the original sample was stratified into three socioeconomic groups: poor, middle and rich. For each maternal health service utilization variable, the gross and net effects of women's education, controlling for age, parity, religion, marital status, health insurance, access to health facilities, partner's education and current place of residence, were estimated using logistic regression, taking into account the complex sampling design of the DHS. The findings revealed country-specific variations in maternal health service utilization, and for most indicators there was a clear gradient among socioeconomic strata: women living in better-off households exhibited greater access to, and utilization of, maternal health services. Multivariate analyses revealed that women's education had a positive association with type of antenatal care provider, timing and frequency of antenatal care visits, place of delivery and presence of a skilled birth attendant at delivery. Many other factors were found to be significantly associated with maternal health service utilization. For instance, parity had a negative and significant association with timing of first antenatal care visit. Likewise, partner's education was positively and statistically associated with timing of first antenatal care visit. It is argued that an over-generalization of the association between women's education and maternal health service utilization can be misleading. Efforts to improve maternal health service utilization in Africa must adopt an 'equity' approach, taking into account the specific needs of sub-populations.