Equity of skilled birth attendant utilization in developing countries: financing and policy determinants

Investigating the role of women's education status and empowerment on accessing skilled birth attendance in Bangladesh: A structural equation modelling approach

BACKGROUND

The objective of this study was to investigate the associations between women's education and access to skilled birth attendant (SBA) services mediated by factors of women's empowerment and sociodemographic characteristics using a path analysis through a structural equation (SEM) modelling approach.

METHODS

A sample of 4946 mothers from the most recent Bangladesh Demographic and Health Survey of 2017-18 was used in the SEM analysis. Accessing SBA service at childbirth was operationalized as utilizing SBA during last childbirth. After extracting the relevant variables and cleaning the original survey data, a subsample of 4,946 women were eligible for analysis in the current study.

RESULTS

The SEM model revealed strong evidence of direct, indirect, and mediating effects of both education and empowerment of women in accessing SBA services. Educated women have more autonomy in decision making and are less susceptible to family violence and consequently are more likely to access SBA services during childbirth (β = 0.094, p < 0.001). In addition, age at first marriage, media exposure, husband's education, healthcare accessibility, decision marking, and household wealth index mediated the relationship between education and SBA service use.

CONCLUSION

Bangladesh, a country that needs to improve several societal and health indices to achieve the Sustainable Development Goals, need to prioritize women's education to increase accessibility to maternal healthcare services. Health education and mass-media-driven awareness may be potential interventions for LMICs to increase SBA coverage.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions

Objective

To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status.

Methods

We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index.

Findings

In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population.

Conclusion

The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Exploring the factors contributing to increase in facility child births in Bangladesh between 2004 and 2017-2018

Background

Although Bangladesh has gained rapid improvement in births at health facilities, yet far behind to achieve the SDG target. Assessing the contribution of factors in increased use of delivery at facilities are important to demonstrate.

Objective

To explore the determinants and their contribution in explaining increased use of facility child births in Bangladesh.

Participants

Reproductive-aged women (15-49 years) of Bangladesh.

Methods and materials

We used the latest five rounds (2004, 2007, 2011, 2014, 2017-2018) of Bangladesh Demographic and Health Surveys (BDHSs). The regression based classical decomposition approach has been used to explore the determinants and their contribution in explaining the increased use of facility child birth.

Results

A sample of 26,686 reproductive-aged women were included in the analysis, 32.90% (8780) from the urban and 67.10% (17,906) from the rural area. We observed a 2.4-fold increase in delivery at facilities from 2004 to 2017-2018, in rural areas it is more than three times higher than the urban areas. The change in mean delivery at facilities is about 1.8 whereas, the predicted change is 1.4. In our full sample model antenatal care visits contribute the largest predicted change of 22.3%, wealth and education contributes 17.3% and 15.3% respectively. For the rural area health indicator (prenatal doctor visit) is the largest drivers contributing 42.7% of the predicted change, hereafter education, demography and wealth. However, in urban area education and health contributed equally 32.0% of the change followed by demography (26.3%) and wealth (9.7%). Demographic variables (maternal BMI, birth order, age at marriage) contributing more than two-thirds (41.2%) of the predicted change in the model without the health variables. All models showed more than 60.0% predictive power.

Conclusion

Health sector interventions should focus both coverage and quality of maternal health care services to sustain steady improvements in child birth facilities.

National Health Spending, Health-Care Resources, Service Utilization, and Health Outcomes

Cross-national studies of the linkage of health-care spending with population health have found surprisingly limited evidence of benefits. In this study, we investigated associations between national health spending and key health resources (numbers of hospital beds, physicians, and nurses) and utilization of cost-effective health services (antenatal care, attendance of trained staff at childbirth, and measles vaccination), sometimes in ways that curtail the benefits of that expenditure. Using annual panel data from 1990-2014 covering 140 countries, we show that variation in health spending as a share of gross domestic product is not associated with decreased mortality rates. It is also very weakly associated with increased health-care resources and health service utilization (elasticity smaller than 0.08), with the association being close to 0 in low-income countries. In addition, countries with a higher share of out-of-pocket spending have a significantly lower level of health resources and service utilization. These findings, rather than the ineffectiveness of health care, could explain the lack of impact of health spending. In contrast, gross domestic product per capita is significantly associated with increased health resources, a higher rate of service utilization, and lower mortality rates, suggesting that income is an important determinant of public health.

Rural-Urban Determinants of Receiving Skilled Birth Attendants among Women in Bangladesh: Evidence from National Survey 2017-18

BACKGROUND

SBAs (skilled birth attendants) play a crucial role in reducing maternal mortality. The proportion of maternal healthcare in Bangladesh that receives quality care at birth has increased; the reasons for this are unknown. The purpose of this study is to see if there has been a change in the use of specific maternal healthcare indicators in urban and rural areas, as well as significant risk factors.

MATERIALS AND METHODS

The data set was extracted from a nationally representative survey based on a cross-sectional study, the Bangladesh Health and Demographic Survey (BDHS) 2017-18. The frequency distribution reveals the general state of SBAs. To identify the association, we performed the chi-square test. Finally, multiple logistic regression was used to analyse the factors associated with SBAs and determine the degree of SBAs disparity between urban and rural areas.

RESULTS

In Bangladesh, 53% of women received SBAs during childbirth, with urban and rural areas receiving 68.1 and 52.2 percent, respectively. Women with secondary (AOR: 1.79, CI: 1.05-3.08) and higher (AOR: 4.18, CI: 2.09-8.50) education were more likely to receive SBAs than women in urban areas who were illiterate. Husband's education, women's working status, wealth index, children's birth order, and number of ANC visit are significant factors in receiving SBSs in both urban and rural areas. Higher educated husbands are 1.83 times (AOR = 1.83, CI: 1.04-3.25, p = 0.037) and 1.82 times (AOR = 1.82, CI: 1.29-2.59, p = 0.001) more likely to attend skilled births than uneducated husbands in both urban and rural areas. Respondents from the richest families are more likely to attend skilled births than those from the poorest families in both urban and rural areas.

CONCLUSION

During delivery, significant risk factors are substantially related to SBAs. More attention must be given to rural and illiterate populations, who are less likely to obtain these services, to minimize maternal and neonatal mortality. Special programs could be developed to raise awareness and facilitate the poor in receiving the basic necessities of maternal care.

Prevalence and factors associated with catastrophic health expenditure among slum and non-slum dwellers undergoing emergency surgery in a metropolitan area of South Western Nigeria

BACKGROUND

Out of Pocket (OOP) payment continues to persist as the major mode of payment for healthcare in Nigeria despite the introduction of the National Health Insurance Scheme (NHIS). Although the burden of health expenditure has been examined in some populations, the impact of OOP among slum dwellers in Nigeria when undergoing emergencies, is under-researched. This study sought to examine the prevalence, factors and predictors of catastrophic health expenditure amongst selected slum and non-slum communities undergoing emergency surgery in Southwestern Nigeria.

METHODS

The study utilised a descriptive cross-sectional survey design to recruit 450 households through a multistage sampling technique. Data were collected using pre-tested semi-structured questionnaires in 2017. Factors considered for analysis relating to the payer were age, sex, relationship of payer to patient, educational status, marital status, ethnicity, occupation, income and health insurance coverage. Variables factored into analysis for the patient were indication for surgery, grade of hospital, and type of hospital. Households were classified as incurring catastrophic health expenditure (CHE), if their OOP expenditure exceeded 5% of payers' household budget. Analysis of the data took into account the multistage sampling design.

RESULTS

Overall, 65.6% (95% CI: 55.6-74.5) of the total population that were admitted for emergency surgery, experienced catastrophic expenditure. The prevalence of catastrophic expenditure at 5% threshold, among the population scheduled for emergency surgeries, was significantly higher for slum dwellers (74.1%) than for non-slum dwellers (47.7%) (F = 8.59; p = 0.019). Multiple logistic regression models revealed the significant independent factors of catastrophic expenditure at the 5% CHE threshold to include setting of the payer (whether slum or non-slum dweller) (p = 0.019), and health insurance coverage of the payer (p = 0.012). Other variables were nonetheless significant in the bivariate analysis were age of the payer (p = 0.017), income (p<0.001) and marital status of the payer (p = 0.022).

CONCLUSION

Although catastrophic health expenditure was higher among the slum dwellers, substantial proportions of respondents incurred catastrophic health expenditure irrespective of whether they were slum or non-slum dwellers. Concerted efforts are required to implement protective measures against catastrophic health expenditure in Nigeria that also cater to slum dwellers.

Women's education and coverage of skilled birth attendance: An assessment of Sustainable Development Goal 3.1 in the South and Southeast Asian Region

Objective

The objective of Sustainable Development Goal 3.1 is to reduce the global maternal mortality ratio (MMR) below 70 per 100,000 live births by 2030. One of the indicators for this objective is the proportion of births attended by skilled health attendants (SBA). This study assessed the progress of low- and middle-income countries from South and Southeast Asian (SSEA) region in SBA coverage and evaluated the contribution of women’s education in this progression.

Methods

The Demographic and Health Surveys were assessed, which included 38 nationally representative surveys on women aged between 15-49 years from 10 selected SSEA region countries in past 30 years. Binary Logistic regression models were fitted adjusting the survey clusters, strata and sampling weights. Meta-analyses were conducted by collapsing effect sizes and confidence intervals of education modeled on SBA coverage.

Results

Results indicated that Cambodia, Indonesia and Philippines had over 80% SBA coverage after 2010, whereas Bangladesh and Afghanistan had around 50% coverage. Women with primary, secondary and higher level of education were 1.65, 2.21 and 3.14 times significantly more likely to access SBA care during childbirth respectively as compared to women with no education, suggesting that education is a key factor to address skilled delivery cares in the SSEA region.

Conclusion

Evaluation of the existing skilled birth attendance policies at the national level could provide useful insight for the decision makers to improve access to skilled care at birth by investing on women’s education in remote and rural areas.

Determinants of antenatal care and skilled birth attendance in sub-Saharan Africa: A multilevel analysis

OBJECTIVE

To determine individual- and country-level determinants of utilization of key maternal health services in sub-Saharan Africa (SSA).

STUDY SETTING

We used the most recent standard demographic and health survey data from the period of 2005 to 2015 for 34 SSA countries. Predictors of key maternal health service indicators were determined using a sample of 245 178 women who had at least one live birth 5 years preceding the survey.

STUDY DESIGN

We used a two-level hierarchical model, considering individual predictors at level one and country factors at level two of the hierarchy.

PRINCIPAL FINDINGS

While the skilled birth attendance (SBA) utilization rate reached 53 percent during the study period, the recommended four or more antenatal care (ANC) coverage was commonly low with less significant differences among different groups of women and countries. Being in a middle-income country increased the individual-level association between ANC and SBA (OR = 2.34, 95% CI: 1.24, 4.44). Less privileged women with lower education level were less likely to receive maternal health services.

CONCLUSIONS

This study reveals the existence of wide gaps between ANC and SBA coverage in SSA. Urgent policy attention is required to improve access, utilization, and quality of maternal health services.

Antenatal care and skilled birth attendance in Bangladesh are influenced by female education and family affordability: BDHS 2014

OBJECTIVES

Antenatal care (ANC) during pregnancy and skilled birth attendance (SBA) during delivery are important policy concerns to reduce maternal deaths. Bangladesh is one of the developing countries which has made remarkable progress in both services during the last couple of decades by improving the SBA service rate from 16% in 2004 to 42.1% in 2014. However, this rate remains below the targeted level (50%) of the Health Population and Nutrition Sector Development Program set by the Ministry of the Health and Family Welfare of Bangladesh. This article explored the sociodemographic factors associated with the ANC and SBA service attainment. Furthermore, the possible implication of using ANC on SBA was also investigated.

STUDY DESIGN

The study followed a cross-sectional design using the Bangladesh demographic and health survey 2014, with a sample of size 4603 women with at least one live birth 3 years preceding the survey.

METHODS

Following a bivariate analysis, linear mixed-effect models were used to assess the relationship between sociodemographic factors and the outcome indicators (ANC and SBA). Finally, the association between SBA and ANC was evaluated through another mixed-effect model.

RESULTS

Wealth index, participation in household decisions, and partner's and respondent's education were significant predictors of ANC; whereas, residence, age at first birth, wealth index, working status, participation in household decisions, and partner and respondent's education were significant for SBA. Female education and household affordability were the strongest predictors for both ANC and SBA. ANC showed significant association with SBA as women accessing essential ANC during delivery seemed to be 4 times more likely (95% confidence interval: 3.05-5.93) to avail SBA services.

CONCLUSIONS

Overall, four factors were significant: residence, wealth index, education, and ANC access. Women residing in urban areas, having higher financial solvency, completing higher education, and accessing ANC by skilled personnel were more likely to receive SBA at delivery than their counterparts. Accessibility to skilled care during pregnancy leads to increased professional care during delivery. Thus, policies to encourage women and heads of families to seek skilled care during pregnancy would be beneficial to reach the maternal healthcare targets of Bangladesh.

Institutional delivery in India, 2004-14: unravelling the equity-enhancing contributions of the public sector

To achieve faster and equitable improvements in maternal and child health outcomes, the government of India launched the National Rural Health Mission in 2005. This paper describes the equity-enhancing role of the public sector in increasing use of institutional delivery care services in India between 2004 and 2014. Information on 24 661 births from nationally representative survey data for 2004 and 2014 is analysed. Concentration index is computed to describe socioeconomic-rank-related relative inequalities in institutional delivery and decomposition is used to assess the contributions of public and private sectors in overall socioeconomic inequality. Multilevel logistic regression is applied to examine the changes in socioeconomic gradient between 2004 and 2014. The analysis finds that utilization of institutional delivery care in India increased from 43% in 2004 to 83% in 2014. The bulk of the increase was in public sector use (21% in 2004 to 53% in 2014) with a modest increase in private sector use (22% in 2004 to 30% in 2014). The shift from a pro-rich to pro-poor distribution of public sector use is confirmed. Decomposition analysis indicates that 51% of these reductions in socioeconomic inequality are associated with improved pro-poor distribution of public sector births. Multilevel logistic regressions confirm the disappearance of a wealth-based gradient in public sector births between 2004 and 2014. We conclude that public health investments in India have significantly contributed towards an equitable increase in the coverage of institutional delivery care. Sustained policy efforts are necessary, however, with an emphasis on education, sociocultural and geographical factors to ensure universal coverage of institutional delivery care services in India.

A cross-sectional study of malaria endemicity and health system readiness to deliver services in Kenya, Namibia and Senegal

Despite good progress towards elimination, malaria continues to contribute substantially to the sub-Saharan African disease burden. Sustaining previous gains requires continued readiness to deliver malaria services in response to actual disease burden, which in turn contributes to health systems strengthening. This study investigates a health system innovation. We examined whether malaria prevalence, or endemicity, is a driver of health facility readiness to deliver malaria services. To estimate this association, we geo-linked cross-sectional facility survey data to endemicity data for Kenya, Namibia and Senegal. We tested the validity and reliability of the primary study outcome, the malaria service readiness index and mapped service readiness components in a geographic information system. We conducted a weighted multivariable linear regression analysis of the relationship between endemicity and malaria service readiness, stratified for urban or rural facility location. As endemicity increased in rural areas, there was a concurrent, modest increase in service readiness at the facility level [β: 0.028; (95% CI 0.008, 0.047)], whereas no relationship existed in urban settings. Private-for-profit facilities were generally less prepared than public [β: -0.102; (95% CI - 0.154, -0.050)]. Most facilities had the necessary supplies to diagnose malaria, yet availability of malaria guidelines and adequately trained staff as well as medicines and commodities varied. Findings require cautious interpretation outside the study sample, which was a more limited subset of the original surveys' sampling schemes. Our approach and findings may be used by national malaria programs to identify low performing facilities in malarious areas for targeted service delivery interventions. This study demonstrates use of existing data sources to evaluate health system performance and to identify within- and cross-country variations for targeted interventions.

Trends and inequities in use of maternal health care services in Indonesia, 1986-2012

Purpose

Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country's maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths.

Methods

Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban-rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis.

Findings

Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth.

Conclusion

Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health.

An equity analysis of utilization of health services in Afghanistan using a national household survey

BACKGROUND

Afghanistan has made great strides in the coverage of health services across the country but coverage of key indicators remains low nationally and whether the poorest households are accessing these services is not well understood.

METHODS

We analyzed the Afghanistan Mortality Survey 2010 on utilization of inpatient and outpatient care, institutional delivery and antenatal care by wealth quintiles. Concentration indexes (CIs) were generated to measure the inequality of using the four services. Additional analyses were conducted to examine factors that explain the health inequalities (e.g. age, gender, education and residence).

RESULTS

Among households reporting utilization of health services, public health facilities were used more often for inpatient care, while they were used less for outpatient care. Overall, the utilization of inpatient and outpatient care, and antenatal care was equally distributed among income groups, with CIs of 0.04, 0.03 and 0.08, respectively. However, the poor used more public facilities while the wealthy used more private facilities. There was a substantial inequality in the use of institutional delivery services, with a CI of 0.31. Poorer women had a lower rate of institutional deliveries overall, in both public and private facilities, compared to the wealthy. Location was an important factor in explaining the inequality in the use of health services.

CONCLUSIONS

The large gap between the rich and poor in access to and utilization of key maternal services, such as institutional delivery, may be a central factor to the high rates of maternal mortality and morbidity and impedes efforts to make progress toward universal health coverage. While poorer households use public health services more often, the use of public facilities for outpatient visits remains half that of private facilities. Pro-poor targeting as well as a better understanding of the private sector's role in increasing equitable coverage of maternal health services is needed. Equity-oriented approaches in health should be prioritized to promote more inclusive health system reforms.

Equity in maternal health care service utilization: a systematic review for developing countries

OBJECTIVES

The objective was to explore progress of equity in the utilization of maternal health care services in developing countries since maternal care is a crucial factor in reducing maternal mortality, which is targeted by the Millennium Development Goal 5.

METHODS

A systematic review of quantitative studies was done. PubMed Central, Web of Science, and Science Direct databases were searched for peer-reviewed and English-language articles published between 2005 and 2015.

RESULTS

Thirty-six articles were included in the review. The results reveal the lack of equity in the utilization of maternal health care in developing countries. Thirty-three out of 36 studies found evidence supporting severe inequities while three studies found evidence of equity or at least improvement in terms of equity.

CONCLUSIONS

Most of the literature devoted to utilization of maternal health care generally provides information on the level of maternal care used and ignore the equity problem. Research in this area should focus not only on the level of maternal care used but also on the most disadvantaged segments of the population in terms of utilization of maternal care in order to reach the set targets.

The link between inequality and population health in low and middle income countries: policy myth or social reality?

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). Our study provides an empirical test of this idea: we utilized data collected by the Demographic and Health Surveys between 2000 and 2011 in as much as 52 LMICs, and we examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women' experience of child mortality. Based on multi-level analyses, we found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when we took into account the level of individuals' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country's level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. We conclude that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.

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

INTRODUCTION

Inequities in accessibility to, and utilisation of maternal healthcare services impede progress towards attainment of the maternal health-related Millennium Development Goals. The objective of this study is to examine the extent to which maternal health services are utilised in Ghana, and whether inequities in accessibility to and utilization of services have been eliminated following the implementation of a user-fee exemption policy, that aims to reduce financial barriers to access, reduce inequities in access, and improve access to and use of birthing services.

METHODS

We analyzed data from the 2007 Ghana Maternal Health Survey for inequities in access to and utilization of maternal health services. In measuring the inequities, frequency tables and cross-tabulations were used to compare rates of service utilization by region, residence and selected socio-demographic variables.

RESULTS

Findings show marginal increases in accessibility to and utilisation of skilled antenatal, delivery and postnatal care services following the policy implementation (2003-2007). However, large gradients of inequities exist between geographic regions, urban and rural areas, and different socio-demographic, religious and ethnic groupings. More urban women (40%) than rural, 53% more women in the highest wealth quintile than women in the lowest, 38% more women in the best performing region (Central Region) than the worst (Upper East Region), and 48% more women with at least secondary education than those with no formal education, accessed and used all components of skilled maternal health services in the five years preceding the survey. Our findings raise questions about the potential equity and distributional benefits of Ghana's user-fee exemption policy, and the role of non-financial barriers or considerations.

CONCLUSION

Exempting user-fees for maternal health services is a promising policy option for improving access to maternal health care, but might be insufficient on its own to secure equitable access to maternal health services in Ghana. Ensuring equity in access will require moving beyond user-fee exemption to addressing wider issues of supply and demand factors and the social determinants of health, including redistributing healthcare resources and services, and redressing the positional vulnerability of women in their communities.

Opportunities and challenges in implementing community based skilled birth attendance strategy in Kenya

Background

Availability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the community midwifery programme in 2005. The aim of this programme was to increase women’s access to skilled care during pregnancy, childbirth and post-partum within their communities.

Methods

Qualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.

Results

Findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options.

Conclusions

Although the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-279) contains supplementary material, which is available to authorized users.

Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District

INTRODUCTION

Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries.

OBJECTIVES

This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services.

METHODS

157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required.

FINDINGS

Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents.

CONCLUSION

TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services.

Intimate partner violence influence on deliveries assisted by skilled health personnel

OBJECTIVE

Millennium Development Goal 5 calls for increasing proportions of deliveries assisted by skilled health personnel to reduce maternal mortality. This study aims to identifying the implication of exposure to intimate partner violence on these proportions.

METHODOLOGY

This study used domestic violence modules data of Demographic and Health Surveys of six countries from 2005 to 2007. Proportions of assisted deliveries were examined by sociodemographic characteristics and exposure to intimate partner violence in the studied countries. Influence on the proportion was examined against exposure to intimate partner violence through odds ratio and 95% of logistic regression analysis after controlling for women age, residence (urban/rural), household wealth level, economic level of country, educational level and working status of women and their husbands/partners.

RESULTS

Data sets of 18,507 participants over 20 years of age showed that almost three-quarters (73%) of women had deliveries assisted by skilled health personnel. One-third of the women were ever exposed to intimate partner violence (37%) and 9% of them to the severe level. Exposure to intimate partner violence statistically significantly lowered this proportion to 69% (odds ratio: 0.73; 95% confidence interval: 0.67-0.78) meanwhile severe violence lowered it to 65% (odds ratio 0.64; 95% confidence interval: 0.58-0.72). When running multiple regression analysis, exposure to intimate partner violence retained its statistically significant decreasing influence on proportions and was not biased by the other stronger socioeconomic characteristics.

CONCLUSION AND RECOMMENDATIONS

Intimate partner violence has an independent influence on reducing assisted deliveries by skilled health personnel. Programs working for increasing proportions of assisted deliveries by skilled health personnel are recommended to integrate protection women from violence.

Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review

While the most important factors associated with facility-based delivery (FBD) have been explored within individual countries in Africa, no systematic review has explored the factors associated with FBD across sub-Saharan Africa. A systematic search of the peer-reviewed literature was conducted to identify articles published in English from 1/1995-12/2011 that reported on original research conducted entirely or in part in sub-Saharan Africa and included a primary outcome variable of FBD, delivery location, or skilled birth attendance (SBA). Out of 1,168 citations identified, 65 met inclusion criteria. 62 of 65 were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorized as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied. This may be a result of the overwhelming reliance on household survey data - where maternal sociodemographic factors are likely to be well-represented and non-maternal factors may be less consistently and accurately represented. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. Research to date has been dominated by analysis of cross-sectional household survey data. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.

Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran

BACKGROUND

Recently, there has been a shift towards alternative childbirth services to increase access to skilled care during childbirth.

OBJECTIVE

This study aims to assess the past 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran to determine the number of deliveries and the intrapartum transfer rates, and to examine the reasons why women choose to give birth at a Safe Delivery Post and not in one of the four large hospitals in Zahedan.

DESIGN

A mixed-methods research strategy was used for this study. In the quantitative phase, an analysis was performed on the existing data that are routinely collected in the health-care sector. In the qualitative phase, a grounded theory approach was used to collect and analyse narrative data from in-depth interviews with women who had given birth to their children at the Safe Delivery Posts.

SETTING

Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran.

PARTICIPANTS

Nineteen mothers who had given birth in the Safe Delivery Posts were interviewed.

FINDINGS

During the 10-year period, 22,753 low-risk women gave birth in the Safe Delivery Posts, according to the records. Of all the women who were admitted to the Safe Delivery Posts, on average 2.1% were transferred to the hospital during labour or the postpartum period. Three key categories emerged from the analysis: barriers to hospital use, opposition to home birth and finally, reasons for choosing the childbirth care provided by the SDPs.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan.

Determinants of non-institutional deliveries in Malawi

Malawi has one of the highest maternal mortality ratios in the world. One of the factors contributing to high maternal mortality is the non-use of health facilities during pregnancy and delivery. The aim of this study is to examine the factors associated with non-institutional deliveries in Malawi. Data from 2004 Malawi Demographic and Health Survey and multinomial logistic regression were used to assess the association between place of delivery and selected socio-economic factors. The study population comprised of 7,218 women, who had at least one child, aged less than five years, at the time the survey. Of these women, 58% delivered at a health facility, 29.4% delivered at home and 12.6% delivered at the home of a traditional birth attendant. Multivariate analysis indicate that region (OR = 1.29 for Central Region), place of residence (OR=0.319 for urban areas), wealth status (OR=6.289 for poor, OR=4.683 for middle), education (OR=3.823 for no education, OR=2.265 for primary education), number of prenatal visits (OR=4.732 no visits, OR=1.696 1-3 visits) and ever use of family (OR=1.29 for never used) showed significant association with non-institutional deliveries. These factors should be considered in designing strategies to improve the maternal health care system in Malawi.

Effect of health insurance on delivery care utilization and perceived delays and barriers among southern Thai women

Background

Financial reform aims to overcome the problems of financial barriers and utilization of health services. However, it is unclear whether financial reforms or health insurance can reduce delays and/or barriers or if there are still other important obstacles for preventing pregnant women accessing delivery care. This study aimed to assess the effect of health insurance and other factors on delivery care utilization and the perception of delays and barriers to delivery care among women living in Songkhla province, Thailand.

Methods

A cross-sectional study was conducted from November 2007 to December 2008. Women who delivered at hospital or home in the areas of participating hospitals in four districts were interviewed at 24- or 48-hours postpartum. The impact of health insurance and other factors on outcomes of interest was assessed using multivariate logistic regression.

Results

Of 2,847 women, 2,822 delivered at a hospital and 25 at home, of which 80% and 40% had health insurance for delivery care, respectively. Muslims, low educated women, those who thought they could not use health insurance for delivery care and those less willing to seek care at their delivery place were more likely to give birth at home. Perception of delays to seeking care, reaching a hospital and receiving care was reduced in women insured by civil servant medical benefit. Women insured by universal coverage and social security perceived a lower delay in reaching a hospital but a higher delay in receiving care. Low education, unwillingness to seek care, out-of-pocket payment, worry about cost of delivery care, transportation difficulties, low perception of receiving good care or a perception of being treated badly were also associated with delays and barriers to health care. Almost all (93%) agreed that health insurance could reduce financial barriers for accessing services. However, having health insurance influenced them to seek care, reach a hospital, and receive care quickly in 50%, 32%, and 23% of the women, respectively.

Conclusions

Health insurance has a significant impact on perceived delays and barriers, but not place of delivery. Socio-economic determinants continue to play an important role for place of delivery and perceived delays and barriers.

Inequities in skilled attendance at birth in Namibia: a decomposition analysis

BACKGROUND

The fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers.

METHODS

Namibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health.

RESULTS

About 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region.

CONCLUSION

Inequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.

Economic status, education and empowerment: implications for maternal health service utilization in developing countries

BACKGROUND

Relative to the attention given to improving the quality of and access to maternal health services, the influence of women's socio-economic situation on maternal health care use has received scant attention. The objective of this paper is to examine the relationship between women's economic, educational and empowerment status, introduced as the 3Es, and maternal health service utilization in developing countries.

METHODS/PRINCIPAL FINDINGS

The analysis uses data from the most recent Demographic and Health Surveys conducted in 31 countries for which data on all the 3Es are available. Separate logistic regression models are fitted for modern contraceptive use, antenatal care and skilled birth attendance in relation to the three covariates of interest: economic, education and empowerment status, additionally controlling for women's age and residence. We use meta-analysis techniques to combine and summarize results from multiple countries. The 3Es are significantly associated with utilization of maternal health services. The odds of having a skilled attendant at delivery for women in the poorest wealth quintile are 94% lower than that for women in the highest wealth quintile and almost 5 times higher for women with complete primary education relative to those less educated. The likelihood of using modern contraception and attending four or more antenatal care visits are 2.01 and 2.89 times, respectively, higher for women with complete primary education than for those less educated. Women with the highest empowerment score are between 1.31 and 1.82 times more likely than those with a null empowerment score to use modern contraception, attend four or more antenatal care visits and have a skilled attendant at birth.

CONCLUSIONS/SIGNIFICANCE

Efforts to expand maternal health service utilization can be accelerated by parallel investments in programs aimed at poverty eradication (MDG 1), universal primary education (MDG 2), and women's empowerment (MDG 3).

Measuring the impact of public health policy

Effective health policies and allocation of public health resources can substantially improve public health. An objective of public health practitioners and researchers is to identify key metrics that would help improve effective policies and terminate poor ones. We review articles published in 2008 surrounding measurement issues for public health policy and present a set of recommendations for future emphasis. We found that a set of consensus metrics for population health performance should be developed. However, considerable work is needed to develop appropriate metrics covering policy approaches that can affect large populations, intervention approaches within organizations, and individual-level behavioral approaches for prevention or disease management.

Progress towards the Millennium Development Goals: a long trek for reproductive health

With only six years remaining to achieve the Millennium Development Goals in 2015, issues pertaining to universal access to reproductive health deserve more emphasis as part of current efforts in international health. The maternal health goal is the Millennium Development Goal with the most disappointing progress. Whereas much has been achieved globally for the utilization of family planning services, there are some geographical areas and subpopulations where progress is lacking. Health systems should be strengthened whilst addressing disparities. The rights and gender aspects of reproductive health have been fully documented, but equitable access and economic aspects should be considered in policy formulation and program implementation. Advocacy is needed for key players to leverage support, whereas efforts for accelerating progress should be sustainable in the long term.

Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

To date, there has been little progress in reducing wealth inequities in access to maternity care. This paper describes the results of a maternal health intervention in Burkina Faso that was aimed at increasing access to skilled maternity care by improving availability and quality of maternity care, particularly at primary care health facilities, and promoting its use before, during, and after delivery. Post-intervention data show a large overall increase in use of facility-based maternity care in the intervention district, particularly at primary care facilities, but little change in the comparison district. In addition, large wealth inequities in the use of professional care during childbirth were almost eliminated in the intervention district while they increased in the comparison district-both among all women, and among the subset of women who reported experiencing complications during delivery. Study results suggest that efforts to upgrade maternity services at primary care facilities may be key for improving poor women's access to and use of skilled care during childbirth.

Socio-economic factors associated with delivery assisted by traditional birth attendants in Iraq, 2000

Background

Traditional birth attendants (TBAs) are likely to deliver lower quality maternity care compared to professional health workers. It is important to characterize women who are assisted by TBAs in order to design interventions specific to such groups. We thus conducted a study to assess if socio-economic status and demographic factors are associated with having childbirth supervised by traditional birth attendants in Iraq.

Methods

Iraqi Multiple Indicator Cluster Survey (MICS) data for 2000 were used. We estimated frequencies and proportions of having been delivered by a traditional birth attendant and other social characteristics. Logistic regression analysis was used to assess the association between having been delivered by a TBA and wealth, area of residence (urban versus rural), parity, maternal education and age.

Results

Altogether 22,980 women participated in the survey, and of these women, 2873 had delivery information and whether they were assisted by traditional birth attendants (TBAs) or not during delivery. About 1 in 5 women (26.9%) had been assisted by TBAs. Compared to women of age 35 years or more, women of age 25–34 years were 22% (AOR = 1.22, 95%CI [1.08, 1.39]) more likely to be assisted by TBAs during delivery. Women who had no formal education were 42% (AOR = 1.42, 95%CI [1.22, 1.65]) more likely to be delivered by TBAs compared to those who had attained secondary or higher level of education. Women in the poorest wealth quintile were 2.52 (AOR = 2.52, 95%CI [2.14, 2.98]) more likely to be delivered by TBAs compared to those in the richest quintile. Compared to women who had 7 or more children, those who had 1 or 2 were 28% (AOR = 0.72, 95%CI [0.59, 0.87]) less likely to be delivered by TBAs.

Conclusion

Findings from this study indicate that having delivery supervised by traditional birth attendants was associated with young maternal age, low education, and being poor. Meanwhile women having 1 or 2 children were less likely to be delivered by TBAs. These factors should be considered in the design of interventions to reduce the rate of deliveries assisted by TBAs in favour of professional midwives, and consequently reduce maternal and neonatal mortality rates and other adverse events.