A comparative study of adult and adolescent maternal care continuum following community-oriented interventions in Cambodia, Guatemala, Kenya, and Zambia

Background The coverage for reproductive care continuum is a growing concern for communities in low- income economies. Adolescents (15–19 years) are often at higher odds of maternal morbidity and mortality due to other underlying factors including biological immaturity, social, and economic differences. The aim of the study was to examine a) differences in care-seeking and continuum of care (4 antenatal care (ANC4+), skilled birth attendance (SBA) and postnatal care (PNC) within 24h) between adult (20–49 Years) and adolescents and b) the effect of multilevel community-oriented interventions on adolescent and adult reproductive care-seeking in Cambodia, Guatemala, Kenya, and Zambia using a quasi-experimental study design. Methods In each country, communities in two districts/sub-districts received timed community health worker (CHW) household health promotion and social accountability interventions with community scorecards. Two matched districts/sub-districts were selected for comparison and received routine healthcare services. Results Results from the final evaluation showed that there were no significant differences in the care continuum for adolescents and adults except for Kenya (26.1% vs 18.8%, p<0.05). SBA was significantly higher for adolescents compared to adult women for Guatemala (64% vs 55.5%, p<0.05). Adolescents in the intervention sites showed significantly higher ANC utilization for Kenya (95.3% vs 84.8%, p<0.01) and Zambia (87% vs 72.7%, p<0.05), ANC4 for Cambodia (83.7% vs 43.2%, p<0.001) and Kenya (65.9% vs 48.1%, p<0.05), SBA for Cambodia (100% vs 88.9%, p<0.05), early PNC for Cambodia (91.8% vs 72.8%, p<0.01) and Zambia (56.5% vs 16.9%, p<0.001) compared to the comparison sites. However, the findings from Guatemala illustrated significantly lower care continuum for intervention sites (aOR:0.34, 95% CI 0.28–0.42, p<0.001). The study provides some evidence on the potential of multilevel community-oriented interventions to improve adolescent healthcare seeking in rural contexts. The predictors of care continuum varied across countries, indicating the importance of contextual factors in designing interventions.

The Extent of Universal Health Coverage for Maternal Health Services in Eastern Uganda: A Cross Sectional Study

Objective Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda. Methods Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence. Results Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women. Conclusion Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research.

Socioeconomic inequalities in access and use of skilled birth attendants during childbirth in Ghana: a decomposition analysis

Background Equitable access to skilled birth attendance during delivery is vital for reducing global maternal deaths to 70 deaths per 100, 000 to achieve the Sustainable Development Goals (SDGs) by 2030. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequalities in access to skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assesses the socioeconomic inequalities in access and use of skilled birth attendants during delivery in Ghana. Methods Research was conducted through literature reviews and document reviews, and a secondary data analysis of the 2014 Ghana Demographic and Health Survey (GDHS), a nationally representative survey. A total of 1305 women aged 15–49 years, who had a live birth the year before to the survey in the presence of a skilled birth attendant were analysed using concentration indices and curves. The indices were further decomposed to identify the major socioeconomic factors contributing most to the inequalities. Results The results found that access to skilled birth attendants was more among women from rich households showing a pro-rich utilization. The decomposition analysis revealed that household wealth index, educational level of both mother and husband/partner, area of residence and mother’s health insurance coverage were the major contributing factors to socioeconomic inequalities in accessing skilled birth attendants during child delivery among Ghanaian women. Conclusion This study confirms that a mother’s socioeconomic status is vital to reducing maternal deaths. Therefore, it is worthy to focus attention on policy interventions to reduce the observed inequalities as revealed in the study.

Early age at first childbirth and skilled birth attendance during delivery among young women in sub-Saharan Africa

Background Despite the numerous policy interventions targeted at preventing early age at first childbirth globally, the prevalence of adolescent childbirth remains high. Meanwhile, skilled birth attendance is considered essential in preventing childbirth-related complications and deaths among adolescent mothers. Therefore, we estimated the prevalence of early age at first childbirth and skilled birth attendance among young women in sub-Saharan Africa and investigated the association between them. Methods Demographic and Health Survey data of 29 sub-Saharan African countries was utilized. Skilled birth attendance and age at first birth were the outcome and the key explanatory variables in this study respectively. Overall, a total of 52,875 young women aged 20-24 years were included in our study. A multilevel binary logistic regression analysis was performed and the results presented as crude and adjusted odds ratios at 95% confidence interval. Results Approximately 73% of young women had their first birth when they were less than 20 years with Chad having the highest proportion (85.7%) and Rwanda recording the lowest (43.3%). The average proportion of those who had skilled assistance during delivery in the 29 sub-Saharan African countries was 75.3% and this ranged from 38.4% in Chad to 93.7% in Rwanda. Young women who had their first birth at the age of 20-24 were more likely to have skilled birth attendance during delivery (aOR = 2.4, CI = 2.24-2.53) than those who had their first birth before 20 years. Conclusion Early age at first childbirth has been found to be associated with low skilled assistance during delivery. These findings re-emphasize the need for sub-Saharan African countries to implement programs that will sensitize and encourage the patronage of skilled birth attendance among young women in order to reduce complications and maternal mortalities. The lower likelihood of skilled birth attendance among young women who had their first birth when they were adolescents could mean that this cohort of young women face some barriers in accessing maternal healthcare services.

Maternity waiting home as a potential intervention for reducing the maternal mortality ratio in El Salvador: an observational case study

Background El Salvador is recognized as a country that has effectively reduced its Maternal Mortality Ratio (MMR). While health indicators, such as total fertility rate, adolescent fertility rate, skilled birth attendance, and health expenditures, have improved in El Salvador, this improvement was unremarkable compared to advancements in other developing countries. How El Salvador could achieve an outstanding decrease in MMR despite unexceptional improvements in health and non-health indicators is a question that deserves deep research. We used quantitative methods and an observational case study to show that El Salvador could reduce its MMR more than expected by instituting health policies that not only aimed to reduce the (adolescent) fertility rate, but also provide safe birthing conditions and medical services to pregnant women through maternity waiting homes. Methods We ran pooled ordinary least squares regression and panel regression with fixed effects using MMR as the dependent variable and health and non-health factors as the independent variables. We conducted residual analysis, calculated the predicted value of MMR, and compared it with the observed value in El Salvador. To explain the change in MMR in El Salvador, we carried out an observational case study of maternity waiting homes in that country. Results El Salvador could reduce MMR by improving health factors such as fertility rate skilled birth attendance and non-health factors, such as gross domestic product (GDP) per capita and female empowerment. However, even while considering these factors, the MMR of El Salvador decreased by more than expected. We confirmed this by analyzing the residuals of the regression model. This improvement in MMR, which is larger than expected from the regression results, can be attributed partly to government measures such as maternity waiting homes. Conclusions The reason for the unexplained reduction in El Salvador’s MMR seems to be attributed in part to health policies that not only aim to reduce the fertility rate but also to provide safe birthing conditions and medical services to pregnant women through maternity waiting homes.

Changes in Inequality in Utilization of Maternal Health Care: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015

Background: The presence of a skilled health professional at delivery is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled births attendance services in Mauritania. The study identifies the inequality determinants and to explore its changes over the period 2007&ndash;2015. Methods: The concentration curve, concentration index, decomposition of the concentration index and Oaxaca-type decomposition technique were performed to measure socio-economics related inequalities in skilled birth attendance services utilization and identify contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007, 2011 and 2015. Results: The concentration index for skilled birth attendance services utilization dropped from 0.6324 [P &lt; 0.001] in 2007 to 0.5852 [P &lt; 0.001] in 2015. Prenatal care, household wealth Status and urban-rural location made the biggest contributions to socio-economic related inequalities. Decomposition of the concentration index and Oaxaca-type decomposition revealed changes prenatal care, rural-urban location made positive contributions to decline in inequality. However, alternation in household wealth score, woman&rsquo;s age, her education level and the number of living children pushed the equality toward deterioration. Conclusion: Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania despite a slight decrease during the study period. Policy actions on eliminating urban-rural and wealth index disparity should target increase access to skilled birth attendance. Multisectoral Policy actions is needed to improve social determinants of health and to remove health system bottlenecks including socio-economic empowerment of women and girls, enhancing availability and affordability of Reproductive and Maternal Health commodities, improving availability of obstetrical providers in rural area, promoting a better distribution and quality of health infrastructure particularly health posts and health centers, and replacing user fees by an equitable, efficient and sustainable financing scheme under an universal health coverage vision.

Stakeholders’ Perspectives on the Implementation of Maternity Waiting Homes in Rural Ethiopia: A Qualitative Study

Background The rural community in Ethiopia is scattered over a wide geographic area, some regions with difficult mountains, making access to healthcare facilities a great challenge. To overcome geographical barriers and improve access to skilled childbirth care, maternity waiting homes (MWHs), shelters built nearby health facilities, where pregnant women are lodged until labour begins, were introduced decades ago. This study identifies the demand and supply-side determinants of access to MWH services in rural Ethiopia. Methods This descriptive, exploratory study included five focus group discussions and eight in-depth interviews using a semistructured interviewer guide. Field notes were collected, and interviews were audio-recorded. Using Quirkois®, data were coded, transcribed verbatim, translated into English, and analyzed following Penchansky and Thomas’s modified framework of access. Results The study identified several challenges of the implementation of the MWH program in the study area. Subthemes that emerged from the discussions were lack of awareness about the MWH services, geographic inaccessibility, inadequacy of facilities and unaffordability-related issues, substandard and culturally insensitive care at MWHs, and logistic barriers. Most participants rated the MWH quality as poor and requested better MWH services to promote access to skilled birth attendance. Conclusions Several contextual, structural and socio-cultural barriers have been hindering the implementation of MWHs in the study area. To improve women’s access to skilled childbirth, it is crucial to tailor context-based MWH messages, upgrade existing MWHs and ensure that the services are culturally sensitive.

Spatial patterns and inequalities in skilled birth attendance and caesarean delivery in sub-Saharan Africa

BackgroundImproved access to and quality obstetric care in health facilities reduces maternal and neonatal morbidity and mortality. We examined spatial patterns, within-country wealth-related inequalities and predictors of inequality in skilled birth attendance and caesarean deliveries in sub-Saharan Africa.MethodsWe analysed the most recent Demographic and Health Survey data from 25 sub-Saharan African countries. We used the concentration index to measure within-country wealth-related inequality in skilled birth attendance and caesarean section. We fitted a multilevel Poisson regression model to identify predictors of inequality in having skilled attendant at birth and caesarean section.ResultsThe rate of skilled birth attendance ranged from 24.3% in Chad to 96.7% in South Africa. The overall coverage of caesarean delivery was 5.4% (95% CI 5.2% to 5.6%), ranging from 1.4% in Chad to 24.2% in South Africa. The overall wealth-related absolute inequality in having a skilled attendant at birth was extremely high, with a difference of 46.2 percentage points between the poorest quintile (44.4%) and the richest quintile (90.6%). In 10 out of 25 countries, the caesarean section rate was less than 1% among the poorest quintile, but the rate was more than 15% among the richest quintile in nine countries. Four or more antenatal care contacts, improved maternal education, higher household wealth status and frequently listening to the radio increased the rates of having skilled attendant at birth and caesarean section. Women who reside in rural areas and those who have to travel long distances to access health facilities were less likely to have skilled attendant at birth or caesarean section.ConclusionsThere were significant within-country wealth-related inequalities in having skilled attendant at birth and caesarean delivery. Efforts to improve access to birth at the facility should begin in areas with low coverage and directly consider the needs and experiences of vulnerable populations.

Access to Facility-Based Childbirth: Women’s Experience on Enablers and Obstacles to the Utilisation of Waiting Mothers’ Shelters in Rural Zimbabwe

This article explores experiences and perceptions of women concerning the utilising a waiting mothers’ shelter at Bonda Mission Hospital in the Manicaland province of Zimbabwe. It draws on a phenomenological qualitative research design. This incorporated in-depth interviews and key informant interviews with purposively selected fifteen women who have used the waiting mothers’ shelter since 2015 and eight healthcare practitioners respectively. The paper is guided by Alfred Schutz’s (1972) social phenomenology. While the findings reveal that most women acknowledged the importance of waiting mothers’ shelters in improving access to skilled birth attendance and maternal health outcomes, there are still factors that militate the use of such innovations. Several socio-cultural and economic factors such as constrained decision making among women, mistreatment and lack of privacy in the shelters are some of the deterrent factors. The article concludes that, although waiting mothers’ shelters are facilities proven to be beneficial in rural communities, they continually face the risk of not being used. There is a need for a multi-stakeholder approach to address the barriers that deter women from utilising the waiting mothers’ shelters and improve access to facility-based delivery, access to skilled birth attendants and enhance the maternal health outcomes in rural communities in Zimbabwe.

What is the Impact of Ante Natal Care (ANC) Attendance on the Subsequent Maternal Health Care Services Utilization in Conflict Affected Area

Background: Somalia has registered 732 maternal mortality every 100,000 live birth; the uptake of maternal health care service is lowest in the world. The purpose of study is to understand social and economic factors that hinder or facilitate the uptake of maternal health care service during the pregnancy in Somalia. Methods: Cross-sectional data was collected from 642 mothers of reproductive age in Mogadishu town through a community survey in November 2020. Descriptive data analysis and propensity score matching models were employed to measure association between the determinants of the uptake of required ANC, Skilled birth attendance and confounding factors. In addition, the impact of minimum ANC attendance on the uptake of mother health care services was evaluated Results: The study indicated that ANC is at its lowest level, only 10% women reported attending 4-ANC[1], 23% didn’t attend any ANC, and 61% attending 1 to 3 ANC; moreover, skilled birth attendance is low rate at 30%, against 67% average in Africa; 78% of women are unable to make decision to visit health clinic or hospital autonomously, rather the decision is made by other people, 44% decision is made by the husband and only 30% jointly by the woman and her husband. Contrary to the data on attendance, about 70% of the surveyed women were aware of health benefits of attending ANC. The cost associated with accessing health service at 31%, distance to health centers, 12%, and perception (ANC is not needed), 23% were the major reasons of not delivering at health institutions.Conclusions: Thus, the number of ANC visits has an incremental positive effect on the probability utilization of skilled birth attendance and delivery at health facility. Access related factors are the most hindering barriers for the poor utilization of health care service as evidently indicated by the negative correlation of distance from health center. Improving access to health education, interventions targeting improved income and women empowerment lead to better maternal health outcome.