Low use of skilled attendants' delivery services in rural Kenya

The aim of the study was to estimate the use of skilled attendants' delivery services among users of antenatal care and the coverage of skilled attendants' delivery services in the general population in Kikoneni location, Kenya. Data collected from the registers at the Kikoneni Health Centre (KHC) from March 2001 through March 2003 were retrospectively reviewed. Antenatal care attendance, deliveries by skilled attendants, and the percentage of antenatal care attendees who delivered in a healthcare facility were assessed. Deliveries at the KHC were compared with expected births in the population to estimate the coverage of deliveries assisted by skilled attendants in the community. Of 994 women who attended the antenatal care clinic, 74 (7.4%) presented for delivery services. 5.4% of expected births in the population occurred in health facilities. The coverage of deliveries assisted by skilled attendants was far below the national and international goals. The use of institutional delivery services was very low even among antenatal care attendees. Targeted programmatic efforts are necessary to increase skilled attendant-assisted births, with the ultimate goal of reducing maternal mortality.     

Skilled care at birth among rural women in Nepal: practice and challenges

In Nepal, most births take place at home, and many, particularly in rural areas, are not attended by a skilled birth attendant. The main objectives of the study were to assess the use of skilled delivery care and barriers to access such care in a rural community and to assess health problems during delivery and seeking care. This cross-sectional study was carried out in two Village Development Committees in Nepal in 2006. In total, 150 women who had a live birth in the 24 months preceding the survey were interviewed using a structured questionnaire. The sample population included married women aged 15-49 years. Forty-six (31%) women delivered their babies at hospital, and 104 (69%) delivered at home. The cost of delivery at hospital was significantly (p < 0.001) higher than that of a delivery at home. Results of univariate analysis showed that women from Brahmin-Chhetri ethnicity, women with higher education or who were more skilled, whose husbands had higher education and more skilled jobs, had first or second childbirth, and having adverse previous obstetric history were associated with institutional delivery while women with higher education and having an adverse history of pregnancy outcome predicted the uptake of skilled delivery care in Nepal. The main perceived problems to access skilled delivery care were: distance to hospital, lack of transportation, lack of awareness on delivery care, and cost. The main reasons for seeking intrapartum care were long labour, retained placenta, and excessive bleeding. Only a quarter of women sought care immediately after problems occurred. The main reasons seeking care late were: the woman or her family not perceiving that there was a serious problem, distance to health facility, and lack of transport. The use of skilled birth attendants at delivery among rural women in Nepal is very poor. Home delivery by unskilled birth attendants is still a common practice among them. Many associated factors relating to the use of skilled delivery care that were identified included age, education and occupation of women, and education and occupation of husbands. Therefore, the availability of skilled delivery care services at the community, initiation of a primary health centre with skilled staff for delivery, and increasing awareness among women to seek skilled delivery care are the best solution.     

Mobilizing communities to improve maternal health: results of an intervention in rural Zambia

Objective

To determine whether a complex community intervention in rural Zambia improved understanding of maternal health and increased use of maternal health-care services.

Methods

The intervention took place in six rural districts selected by the Zambian Ministry of Health. It involved community discussions on safe pregnancy and delivery led by trained volunteers and the provision of emergency transport. Volunteers worked through existing government-established Safe Motherhood Action Groups. Maternal health indicators at baseline were obtained from women in intervention (n = 1775) and control districts (n = 1630). The intervention’s effect on these indicators was assessed using a quasi-experimental difference-in-difference approach that involved propensity score matching and adjustment for confounders such as education, wealth, parity, age and distance to a health-care facility.

Findings

The difference-in-difference comparison showed the intervention to be associated with significant increases in maternal health indicators: 14–16% in the number of women who knew when to seek antenatal care; 10–15% in the number who knew three obstetric danger signs; 12–19% in those who used emergency transport; 22–24% in deliveries involving a skilled birth attendant; and 16–21% in deliveries in a health-care facility. The volunteer drop-out rate was low. The estimated incremental cost per additional delivery involving a skilled birth attendant was around 54 United States dollars, comparable to that of other demand-side interventions in developing countries.

Conclusion

The community intervention was associated with significant improvements in women’s knowledge of antenatal care and obstetric danger signs, use of emergency transport and deliveries involving skilled birth attendants.     

Preferences for home delivery in Ethiopia: Provider perspectives

More than half of the maternal deaths worldwide occur in sub-Saharan Africa, most commonly during childbirth or the immediate post-partum period. Although delivery in health care facilities can avert maternal deaths, many women in sub-Saharan Africa continue to deliver at home. Factors influencing mothers' decisions to use facility-based delivery services in rural, low-income settings are not well understood. Health care professionals who provide delivery services in these areas may have unique insights about factors specific to such settings. Accordingly, we conducted a qualitative study of health care professionals in rural Ethiopia to determine key factors influencing facility delivery, using in-depth interviews and the constant comparative method of data analysis. Results suggest multiple influences on women's decisions to deliver at home, including inadequate resources in facilities; unappealing aspects of delivery in facility settings; and known barriers to accessing services such as distance, transportation and cost. Our findings suggest that local health care providers offer valuable insight into why many rural Ethiopian women deliver their babies at home, despite major efforts to promote facility-based delivery. Their perspectives underscore the importance of a patient-centred approach to delivery services, which is often lacking in low-resource settings but may be fundamental to encouraging facility-based deliveries.     

Intimate Partner Violence and the Utilization of Maternal Health Care Services in Nigeria

Our aim in this study is to examine the association between women's lifetime experiences of physical, sexual, and emotional intimate partner violence (IPV) and the use of maternal health care services. We used data from the 2008 Nigeria Demographic and Health Survey. Analysis was based on responses from 17,476 women (for antenatal care [ANC]) and 17,412 (for delivery assisted by a skilled health provider) who had had deliveries in the 5 years preceding the survey. We found an overall IPV prevalence rate of 33.4%. Physical IPV was associated with low use of ANC. Emotionally abused women were less likely to use delivery assistance from skilled health care providers. Based on our findings, we suggest the importance of designing interventions to address the health care needs of women who have experienced violence from their partners.     

The Constraints of Distance and Poverty on Institutional Deliveries in Pakistan: Evidence from Georeference‐Linked Data

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed‐effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life‐threatening complications of childbirth.     

Differentials in neonatal mortality in two adjacent rural areas of Bangladesh: Lessons for neonatal health interventions

Abstract

A household survey, conducted in three rural sub-districts of northeastern Bangladesh, revealed a markedly lower neonatal mortality rate (NMR) in one sub-district compared to two adjacent sub-districts. This study examines the degree to which the differential in NMR can be explained by factors that could be improved by maternal and newborn health programmes, such as knowledge of danger signs and use of antenatal, delivery, and postnatal care. Use of a skilled birth attendant in uncomplicated deliveries, mothers’ knowledge of newborn complications, and use of health care for sick newborns accounted for 32% of the differential in NMR. Pregnancy and delivery complications were associated with increased risk of neonatal mortality, and distance to nearest emergency obstetric care facility was significantly associated with lower risk of neonatal mortality. Therefore, health programmes to improve mothers’ knowledge of newborn complications, to increase access to emergency obstetric care, and to promote appropriate use of health care could significantly reduce neonatal mortality in impoverished communities.     

‘A Normal Delivery Takes Place at Home’: A Qualitative Study of the Location of Childbirth in Rural Ethiopia

To identify reasons why women who access health facilities and utilise maternal newborn and child health services at other times, do not necessarily deliver at health facilities. Forty-six semi-structured interviews were conducted with mothers who had recently delivered (n = 30) or were pregnant (n = 16). Thematic analysis of the interview data resulted in emerging trends that were critically addressed according to the research objective. Of the 30 delivered cases, 14 had given birth at a health facility, but only 3 of those had planned to do so. The remaining 11 had attended due to long or complicated labours. Five dominant themes influencing location of delivery were identified: perceptions of a normal delivery; motivations encouraging health facility delivery; deterrents preventing health facility deliveries; decision-making processes; and level of knowledge and health education. Understanding the socio-cultural determinants that influence the location of delivery has implications for service provision. Alongside timely health education and maximising the contact between women and healthcare professionals, these determinants should be actively incorporated into maternal newborn and child health policy and programming in ways that encourage the utilisation of health facilities, even for routine deliveries.     

Birth-preparedness for maternal health: findings from Koupéla District, Burkina Faso

Maternal mortality is a global burden, with more than 500,000 women dying each year due to pregnancy and childbirth-related complications. Birth-preparedness and complication readiness is a comprehensive strategy to improve the use of skilled providers at birth, the key intervention to decrease maternal mortality. Birth-preparedness and complication readiness include many elements, including: (a) knowledge of danger signs; (b) plan for where to give birth; (c) plan for a birth attendant; (d) plan for transportation; and (e) plan for saving money. The 2003 Burkina Faso Demographic and Health Survey indicated that only 38.5% of women gave birth with the assistance of a skilled provider. The Maternal and Neonatal Health Program of JHPIEGO implemented a district-based model service-delivery system in Koupéla, Burkina Faso, during 2001-2004, to increase the use of skilled providers during pregnancy and childbirth. In 2004, a cross-sectional survey with a random sample of respondents was conducted to measure the impact of birth-preparedness and complication readiness on the use of skilled providers at birth. Of the 180 women who had given birth within 12 months of the survey, 46.1% had a plan for transportation, and 83.3% had a plan to save money. Women with these plans were more likely to give birth with the assistance of a skilled provider (p=0.07 and p=0.03 respectively). Controlling for education, parity, average distance to health facility, and the number of antenatal care visits, planning to save money was associated with giving birth with the assistance of a skilled provider (p=0.05). Qualitative interviews with women who had given birth within 12 months of the survey (n=30) support these findings. Most women saved money for delivery, but had less concrete plans for transportation. These findings highlight how birth-preparedness and complication readiness may be useful in increasing the use of skilled providers at birth, especially for women with a plan for saving money during pregnancy.     

Source of Antenatal Care Influences Facility Delivery in Rural Tanzania: A Population-Based Study

Objective While antenatal care does not directly contribute to reducing maternal mortality, it may play an indirect role by encouraging women to deliver with a skilled birth attendant or in a health facility. We investigated whether the frequency of visits and select characteristics of antenatal care were associated with facility delivery. Methods We selected a population-representative sample of households in a rural district of western Tanzania. Women who had given birth within five years were asked about their most recent delivery and antenatal care. Results Of 1,204 women interviewed, 1,195 (99.3%) made at least one antenatal care visit, while only 438 (36.4%) delivered in a health facility. In adjusted analysis, women were significantly more likely to deliver in a health facility if they attended antenatal care at a government health center (OR 3.17, 95% CI: 1.60–6.30) or a mission facility (OR 2.87, 95% CI: 1.36–6.07), rather than a government dispensary. Women were significantly less likely to deliver in a health facility if their nearest health facility was outside their village (OR 0.38, 95% CI: 0.22–0.66). Conclusion Though facility utilization for antenatal care is frequent, most women who accessed antenatal care did not deliver in a health facility. Women who obtained antenatal care at higher level government facilities or mission facilities, which offered better quality of care, were more likely to deliver in any facility. Improving the quality of antenatal care may improve the health of mothers through encouraging women to return to facilities for delivery.     

Health Status and Health Insurance Coverage of Women with Live-Born Infants: An Opportunity for Preventive Services After Pregnancy

Most women in the US have access to health care and insurance during pregnancy; however women with Medicaid-paid deliveries lose Medicaid eligibility in the early postpartum period. This study examined the association between health insurance coverage at the time of delivery and health conditions that may require preventive or treatment services extending beyond pregnancy into the postpartum period. We used 2008 Pregnancy Risk Assessment Monitoring System data from 27 states (n = 35,980). We calculated the prevalence of maternal health conditions, including emotional and behavioral risks, by health insurance status at the time of delivery. We used multivariable logistic regression to assess the association between health insurance coverage, whether Medicaid or private, and maternal health status. As compared to women with private health insurance, women with Medicaid-paid deliveries had higher odds of reporting smoking during pregnancy (adjusted odds ratio [AOR]: 1.85, 95 % confidence interval [CI]: 1.56–2.18), physical abuse during pregnancy (AOR: 1.73, 95 % CI: 1.24–2.40), having six or more stressors during pregnancy (AOR: 2.48, 95 % CI: 1.93–3.18), and experiencing postpartum depressive symptoms (AOR: 1.24, 95 % CI: 1.04–1.48). There were no significant differences by insurance status at delivery in pre-pregnancy overweight/obesity, pre-pregnancy physical activity, weight gain during pregnancy, alcohol consumption during pregnancy, or postpartum contraceptive use. Compared to women with private insurance, women with Medicaid-paid deliveries were more likely to experience risk factors during pregnancy such as physical abuse, stress, and smoking, and postpartum depressive symptoms for which continued screening, counseling, or treatment in the postpartum period could be beneficial.     

Timely implementation of interventions to reduce vertical HIV transmission: a successful experience in Brazil]

OBJECTIVE: To describe the impact, at the public maternity facility of a university hospital in Brazil, of the rapid implementation of new guidelines recommended by national consensus panels concerning the prevention of vertical HIV transmission. METHOD: We performed a retrospective study of deliveries by HIV-infected women at the public maternity facility of a university hospital in the city of Campinas, S?o Paulo, Brazil, from 1990 through 2000. The guidelines utilized at the facility during this period were: (1) from 1990 through 1994, contraindication to breast-feeding and no use of antiretroviral drugs; (2) 1995 and 1996, use of zidovudine (AZT) by the pregnant woman and the newborn; (3) 1997 and 1998, use of AZT according to the ACTG 076 protocol; and (4) 1999 and 2000, multiple antiretroviral agents and elective cesarean delivery. All the antiretroviral drugs were provided for free by Brazil's public health care system. The vertical transmission rate was calculated for each of the four stages, and the risk ratio for congenital transmission was calculated for each stage and for each prophylactic intervention separately (breast-feeding, type of antiretroviral drug, type of delivery). RESULTS: We studied 197 deliveries at the public maternity facility over that 1990-2000 period. Over the four stages, the rate of vertical transmission decreased: it was 32.3% in the first stage, 25.7% in the second, 2.2% in the third, and 2.9% in the fourth. The most pronounced decrease, observed from the second to the third stage, occurred after introduction of the full ACTG 076 regimen. The use of combined antiretroviral agents increased from 0% in the first stage to 46.4% in the fourth stage. There were no cases of vertical transmission in pregnant women treated with multiple drugs. The risk of vertical HIV transmission was 5 times as great with breast-feeding vs. no breast-feeding (risk ratio = 5.06), 5 times as great with no antiretroviral therapy vs. the full ACTG 076 regimen (risk ratio = 5.29), and 4 times as great with forceps delivery vs. elective cesarean delivery (risk ratio = 4.13). CONCLUSION: The timely adoption of up-to-date interventions recommended by national consensus panels, along with the free provision of antiretroviral drugs, was effective in reducing congenital HIV transmission in this public maternity facility. The interaction between the university hospital health service and the public health service reduced the time needed for implementation of proven, effective interventions, and this experience could serve as an example for other maternal and perinatal health situations.     

Being Insured Improves Safe Delivery Practices in Rwanda

Rwanda still faces major hurdles in its effort to achieve universal access to health care for all. Even though there is an improvement in overall population health status and community-based funding of insurance coverage, a large percentage of women still deliver their babies at home assisted by unskilled birth attendants or unassisted. This paper examines the relationship between being insured and delivery at home and delivery by an unskilled attendant/unassisted. It is evident that uninsured women are significantly more likely to deliver their babies at home by an unskilled birth attendant/unassisted. Moreover, taking other factors into consideration, women who delivered at home are more likely to have no formal education, reside in a rural area, work in the agricultural sector, and are in the poorest household quintile. Findings from this study suggest that being insured may lift financial barriers and encourage women to deliver their babies in a health facility by a skilled birth attendant. Nonetheless, when health insurance status is controlled in multivariate models, certain socioeconomic inequalities do exist for women giving birth in a health facility and by a skilled birth attendant. These inequalities should decline when the insured population increases.     

A Qualitative Evaluation of the Choice of Traditional Birth Attendants for Maternity Care in 2008 Sierra Leone: Implications for Universal Skilled Attendance at Delivery

Maternal and newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities; and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.     

Use of Health Professionals for Delivery Following the Availability of Free Obstetric Care in Northern Ghana

Objectives To assess the factors associated with the use of health professionals for delivery following the implementation of a free obstetric care policy in the poorest regions of Ghana. Methods All 4,070 women identified in the Navrongo demographic surveillance system with pregnancy outcomes in the Kassena-Nankana district between January 1 and December 31, 2004 were eligible for the study. Three thousand four hundred and thirty three women completed interviews on socio-demographic and pregnancy related factors. Information on 259 communities including travel distance to the nearest health facility was also obtained. Multilevel logistic regression analyses were conducted. Results ninety eight percent of women received antenatal care but only 38% delivered with the assistance of health professionals. In a multilevel logistic model, physical access factors {such as availability of public transport, odds ratio (OR) = 1.50 (1.15-1.94), travel distance to the district hospital [for 20+ km, OR = 0.31 (0.23-0.43)] as well as community perception of access to the nearest health facility [for highest quintile, OR = 4.44 (2.88-6.84)]} showed statistically significant associations with use of health professionals at last delivery. Women who knew that delivery care was free of charge were 4.6 times more likely to use health professionals. Higher parity was strongly negatively associated with use of health professionals [OR = 0.37 (0.29-0.48) for parity >/=4 compared to parity 0-1]. However, community perception of quality of care was not associated with use of health professionals for delivery. Conclusion Physical access factors remain strong determinants of use of professional delivery care in rural northern Ghana.     

What does Access to Maternal Care Mean Among the Urban Poor? Factors Associated with Use of Appropriate Maternal Health Services in the Slum Settlements of Nairobi, Kenya

Objectives The study seeks to improve understanding of maternity health seeking behaviors in resource-deprived urban settings. The objective of this paper is to identify the factors which influence the choice of place of delivery among the urban poor, with a distinction between sub-standard and “appropriate” health facilities. Methods The data are from a maternal health project carried out in two slums of Nairobi, Kenya. A total of 1,927 women were interviewed, and 25 health facilities where they delivered, were assessed. Facilities were classified as either “inappropriate” or “appropriate”. Place of delivery is the dependent variable. Ordered logit models were used to quantify the effects of covariates on the choice of place of delivery, defined as a three-category ordinal variable. Results Although 70% of women reported that they delivered in a health facility, only 48% delivered in a facility with skilled attendant. Besides education and wealth, the main predictors of place of delivery included being advised during antenatal care to deliver at a health facility, pregnancy “wantedness”, and parity. The influence of health promotion (i.e., being advised during antenatal care visits) was significantly higher among the poorest women. Conclusion Interventions to improve the health of urban poor women should include improvements in the provision of, and access to, quality obstetric health services. Women should be encouraged to attend antenatal care where they can be given advice on delivery care and other pregnancy-related issues. Target groups should include poorest, less educated and higher parity women.     

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

Two decades after the Safe Motherhood campaigns 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries.     

Maternal and child health in Yushu, Qinghai Province, China

Introduction

Surmang, Qinghai Province is a rural nomadic Tibetan region in western China recently devastated by the 2010 Yushu earthquake; little information is available on access and coverage of maternal and child health services.

Methods

A cross-sectional household survey was conducted in August 2004. 402 women of reproductive age (15-50) were interviewed regarding their pregnancy history, access to and utilization of health care, and infant and child health care practices.

Results

Women's access to education was low at 15% for any formal schooling; adult female literacy was <20%. One third of women received any antenatal care during their last pregnancy. Institutional delivery and skilled birth attendance were <1%, and there were no reported cesarean deliveries. Birth was commonly attended by a female relative, and 8% of women delivered alone. Use of unsterilized instrument to cut the umbilical cord was nearly universal (94%), while coverage for tetanus toxoid immunization was only 14%. Traditional Tibetan healers were frequently sought for problems during pregnancy (70%), the postpartum period (87%), and for childhood illnesses (74%). Western medicine (61%) was preferred over Tibetan medicine (9%) for preventive antenatal care. The average time to reach a health facility was 4.3 hours. Postpartum infectious morbidity appeared to be high, but only 3% of women with postpartum problems received western medical care. 64% of recently pregnant women reported that they were very worried about dying in childbirth. The community reported 3 maternal deaths and 103 live births in the 19 months prior to the survey.

Conclusions

While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in Surmang suffer from substantial health inequities in access to antenatal, skilled birth and postpartum care. Institutional delivery, skilled attendance and cesarean delivery are virtually inaccessible, and consequently maternal and infant morbidity and mortality are likely high. Urgent action is needed to improve access to maternal, neonatal and child health care in these marginalized populations. The reconstruction after the recent earthquake provides a unique opportunity to link this population with the health system.