Rural/Urban and Socioeconomic Differentials in Quality of Antenatal Care in Ghana

BackgroundApproximately 800 women die of pregnancy-related complications every day. Over half of these deaths occur in sub-Saharan Africa (SSA). Most maternal deaths can be prevented with high quality maternal health services. It is well established that use of maternal health services vary by place of residence and socioeconomic status (SES), but few studies have examined the determinants of quality of maternal health services in SSA. The purpose of this study is to examine the determinants of antenatal care (ANC) quality in Ghana–focusing on the role of place of residence and SES (education and wealth). The analysis also examines the interactions of these variables and the mediating role of ANC timing, frequency, facility type, and provider type.MethodsThe data are from the Ghana Maternal Health Survey (N = 4,868). Analytic techniques include multilevel linear regression with mediation and moderation analysis.ResultsUrban residence and higher SES are positively associated with higher ANC quality, but the urban effect is completely explained by sociodemographic factors. Specifically, about half of the urban effect is explained by education and wealth alone, with other variables accounting for the remainder. The effects of education are conditional on wealth and are strongest for poor women. Starting ANC visits early and attending the recommended four visits as well as receiving ANC from a higher level facility and from a skilled provider are associated with higher quality ANC. These factors partially explain the SES differentials.ImplicationsGhanaian women experience significant disparities in quality of ANC, with poor illiterate women receiving the worst care. Targeted efforts to increase quality of ANC may significantly reduce maternal health disparities in Ghana and SSA. A particularly crucial step is to improve ANC quality in the lower level health facilities, where the most vulnerable women are more likely to seek ANC.     

Effect of Media Use on HIV/AIDS-Related Knowledge and Condom Use in Sub-Saharan Africa: A Cross-Sectional Study

It is known that the level of HIV/AIDS-related knowledge and the degree of condom use varies by socioeconomic status (SES). However, there is limited research on the effect of mass media use on HIV/AIDS-related cognitive and behavioral outcomes in low-income countries and how it might influence the association between SES and HIV-related outcomes. We investigated the moderating effect of media use on the relationship between SES and HIV/AIDS-related knowledge and condom use in sub-Saharan Africa in terms of communication inequalities. Cross-sectional data from the Demographic Health Surveys from 13 sub-Saharan countries (2004–10) were pooled. Gender-stratified multivariable poisson regression of 151,209 women and 68,890 men were used to calculate adjusted relative ratios and 95% confidence intervals for the associations between SES, media use, HIV-related outcomes, and condom use. We found significant disparities in mass media use among people from different SES groups as well as among countries. Education and wealth are strongly and positively associated with awareness of HIV/AIDS and knowledge about transmission and prevention of HIV/AIDS and are significantly associated with condom use. These associations are attenuated when the use of various types of mass media is added to the models, with newspapers showing the strongest effect. The findings of this study suggest that media use has the potential to blunt the impact of socioeconomic status though not completely eliminate it. Thus, we need to pay attention to reducing communication inequalities among social groups and countries to moderate the effect of wealth and SES on HIV/AIDS.     

Factors influencing appropriate use of interventions for management of women experiencing preterm birth: A mixed-methods systematic review and narrative synthesis

BackgroundPreterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management.Methods and findingsWe conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings.ConclusionsIn this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.

Rana Islamiah Zahroh and colleagues explore factors influencing appropriate use of interventions for management of women experiencing preterm birth globally.     

Socioeconomic status as a risk factor for HIV infection in women in East, Central and Southern Africa: a systematic review

This is a critical, systematic review of the relationship between socioeconomic status (SES) and HIV infection in women in Southern, Central and Eastern Africa. In light of the interest in micro-credit programmes and other HIV prevention interventions structured to empower women through increasing women's access to funds and education, this review examines the epidemiological and public health literature, which ascertains the association between low SES using different measurements of SES and risk of HIV infection in women. Also, given the focus on structural violence and poverty as factors driving the HIV epidemic at a structural/ecological level, as advocated by Paul Farmer and others, this study examines the extent to which differences in SES between individuals in areas with generalized poverty affect risk for SES. Out of 71 studies retrieved, 36 studies met the inclusion criteria including 30 cross-sectional, one case-control and five prospective cohort or nested case-control studies. Thirty-five studies used at least one measurement of female's SES and fourteen also included a measurement of partner's SES. Studies used variables measuring educational level, household income and occupation or employment status at the individual and neighbourhood level to ascertain SES. Of the 36 studies, fifteen found no association between SES and HIV infection, twelve found an association between high SES and HIV infection, eight found an association between low SES and HIV infection and one was mixed. In interpreting these results, this review examines the role of potential confounders and effect modifiers such as history of STDs, number of partners, living in urban or rural areas and time and location of study in sub-Saharan Africa. It is argued that STDs and number of partners are on the causal pathway under investigation between HIV and SES and should not be adjusted as confounders in any analysis. In conclusion, it is argued that in low-income sub-Saharan Africans countries, where poverty is widespread, increasing access to resources for women may initially increase risk of HIV or have no effect on risk-taking behaviours. In some parts of Southern Africa where per capita income is higher and within-country inequalities in wealth are greater, studies suggest that increasing SES may decrease risk. This review concludes that increased SES may have differential effects on married and unmarried women and further studies should use multiple measures of SES. Lastly, it is suggested that the partner's SES (measured by education or income/employment) may be a stronger predictor of female HIV serostatus than measures of female SES.     

The Relationship of Ethnicity,Socioeconomic Factors,and Overweight in U.S. Adolescents

Objective: To examine the extent to which race/ethnic differences in income and education account for sex‐specific disparities in overweight prevalence in white, African American, Hispanic, and Asian U.S. teens. Research Methods and Procedures: We used nationally representative data collected from 13,113 U.S. adolescents enrolled in the National Longitudinal Study of Adolescent Health. Logistic regression models were used to examine the relationship of family income and parental education to overweight prevalence (body mass index ≥ 85th percentile of age and sex‐specific cutoff points from the 2000 Centers for Disease Control and Prevention/National Center for Health Statistics growth charts). In addition, we used coefficients from our logistic regression models to project the effects on overweight prevalence of equalizing the socioeconomic status (SES) differences between race/ethnic groups. Results: Keeping adolescents in their same environments and changing only family income and parental education had a limited effect on the disparities in overweight prevalence. Ethnicity‐SES‐overweight differences were greater among females than males. Given that overweight prevalence decreased with increasing SES among white females and remained elevated and even increased among higher SES African‐American females, African‐American/white disparity in overweight prevalence increased at the highest SES. Conversely, disparity was lessened at the highest SES for white, Hispanic, and Asian females. Among males, disparity was lowest at the average SES level. Discussion: One cannot automatically assume that the benefits of increased SES found among white adults will transfer to other gender‐age‐ethnic groups. Our findings suggest that efforts to reduce overweight disparities between ethnic groups must look beyond income and education and focus on other factors, such as environmental, contextual, biological, and sociocultural factors.     

Site-specific risk factors for colorectal cancer in a Korean population

We investigated the association of colorectal cancer risk factors with different colorectal cancer subsites to assess etiological differences for cancers of the proximal colon, distal colon, and rectum. Included in this study were 869,725 men and 395,501 women who participated in a health examination provided by the Korean National Health System between 1996 and 1997. During up to 7 years of follow-up, 4,144 incident colorectal cancer cases were detected (3,051 men and 1,093 women). Greater height was associated with elevated risk for distal colon cancer and rectal cancer in both men and women. Family history of cancer was associated with higher risk for cancers of the proximal colon in men and distal colon in both men and women. Frequent alcohol consumption and consuming high amounts of alcohol were associated with elevated risk for distal colon cancer in men and higher risk for rectal cancer in women. Frequent meat consumption was associated with risk for proximal colon cancer in men and for rectal cancer in women. Our findings suggest that risk factors for colorectal cancer are different by subsites of colon and rectum, as well as by sex.     

Socioeconomic Inequalities in Childhood Undernutrition in India: Analyzing Trends between 1992 and 2005

Background

India experienced a rapid economic boom between 1991 and 2007. However, this economic growth has not translated into improved nutritional status among young Indian children. Additionally, no study has assessed the trends in social disparities in childhood undernutrition in the Indian context. We examined the trends in social disparities in underweight and stunting among Indian children aged less than three years using nationally representative data.

Methods

We analyzed data from the three cross-sectional rounds of National Family Health Survey of India from 1992, 1998 and 2005. The social factors of interest were: household wealth, maternal education, caste, and urban residence. Using multilevel modeling to account for the nested structure and clustering of data, we fit multivariable logistic regression models to quantify the association between the social factors and the binary outcome variables. The final models additionally included age, gender, birth order of child, religion, and age of mother. We analyzed the trend by testing for interaction of the social factor and survey year in a dataset pooled from all three surveys.

Results

While the overall prevalence rates of undernutrition among Indian children less than three decreased over the 1992–2005 period, social disparities in undernutrition over these 14 years either widened or stayed the same. The absolute rates of undernutrition decreased for everyone regardless of their social status. The disparities by household wealth were greater than the disparities by maternal education. There were no disparities in undernutrition by caste, gender or rural residence.

Conclusions

There was a steady decrease in the rates of stunting in the 1992–2005 period, while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005. Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children. The high rates of undernutrition (even among the socially advantaged groups) and the persistent social disparities need to be addressed in an urgent and comprehensive manner.     

Socio-Economic Disparities in Use of Family Planning Methods among Pakistani Women: Findings from Pakistan Demographic and Health Surveys

BackgroundSeveral developing countries like Pakistan step into Sustainable Development Goals period with crucial maternal and child health needs that need to be addressed for improving health outcomes among people. We aim to explore existent socio-economic disparities in use of family planning methods (FPM) among Pakistani women, and compare any such inequalities between the years 2006 and 2013.SettingPakistan Demographic and Health Surveys (PDHS) 2006–7 (n = 9177) and the most recent 2012–13(n = 13558) data were used to conduct secondary analysis. Participants were ever married women aged between 15 and 49 years. Socio-economic status was assessed by the education level and wealth index. Inequalities were measured through Odds Ratio (OR), Relative Index of inequality (RII), and Slope index of inequality (SII) on non-use of FPM.ResultsAlthough the prevalence of FPM use has increased over time (28% in 2006 versus 54% in 2013), the socio-economic inequalities persistently exist. Comparing results of PDHS 2006 with PDHS 2013, education related absolute inequalities among urban dwellers increased from -0.41 (95% CI -0.67, -0.13, p-value < 0.01) to -0.83 (95% CI -1.02, -0.63, p-value < 0.01); and increased from -0.93 (95% CI -1.21, -0.64, p-value < 0.01) to -0.98 (95% CI -1.20, -0.76, p-value < 0.01) among rural dwellers. Similarly wealth related absolute inequalities are also existent.ConclusionsAlthough the FPM use has increased over time, but it is important to note that socio-economic gap in use of FPM persists. Such differences have disadvantaged the poor and the illiterate. Family planning programs may target the disadvantaged subgroups for ensuring well-being of women and children in Pakistan.     

Correction: Maternity protection entitlements for non-standard workers in low-and-middle-income countries and potential implications for breastfeeding practices: a scoping review of research since 2000

Almost half of all pregnant women in the United States gain weight above Institute of Medicine gestational weight gain guidelines. Breastfeeding has been shown to reduce weight retention in the first year postpartum; however, women with lower socioeconomic status (SES) tend to initiate breastfeeding less often than women with higher SES. We investigated associations between duration of breastfeeding with mother’s long-term postpartum weight status at 4–10 years and evaluated whether the associations varied by SES. Maternal and infant dyads (N?=?2144 dyads) are from the Geographic Research on Wellbeing survey (GROW), 2012–2013, a long-term, cross-sectional follow-up of the Maternal and Infant Health Assessment (MIHA) based in California, USA. Pre-pregnancy body mass index (BMI) was obtained from self-report of height and weight during MIHA, while breastfeeding history and self-report of current body weight was collected at the 4–10 year GROW postpartum visit. SES score was derived from a composite score of percent federal poverty level and education and was dichotomized into High and Low SES groups at a score of three. Multivariable linear regression was used to examine association between breastfeeding and maternal weight status, and to examine for effect modification by SES. Average long-term weight retention 4–10 years postpartum was 4.0 kg. Fewer lower SES vs. higher SES women breast fed at least six months (51% versus 70%, p?相似文献   

Social inequalities of functioning and perceived health in Switzerland--a representative cross-sectional analysis

Many people worldwide live with a disability, i.e. limitations in functioning. The prevalence is expected to increase due to demographic change and the growing importance of non-communicable disease and injury. To date, many epidemiological studies have used simple dichotomous measures of disability, even though the WHO's International Classification of Functioning, Disability, and Health (ICF) provides a multi-dimensional framework of functioning. We aimed to examine associations of socio-economic status (SES) and social integration in 3 core domains of functioning (impairment, pain, limitations in activity and participation) and perceived health. We conducted a secondary analysis of representative cross-sectional data of the Swiss Health Survey 2007 including 10,336 female and 8,424 male Swiss residents aged 15 or more. Guided by a theoretical ICF-based model, 4 mixed effects Poisson regressions were fitted in order to explain functioning and perceived health by indicators of SES and social integration. Analyses were stratified by age groups (15-30, 31-54, ≥55 years). In all age groups, SES and social integration were significantly associated with functional and perceived health. Among the functional domains, impairment and pain were closely related, and both were associated with limitations in activity and participation. SES, social integration and functioning were related to perceived health. We found pronounced social inequalities in functioning and perceived health, supporting our theoretical model. Social factors play a significant role in the experience of health, even in a wealthy country such as Switzerland. These findings await confirmation in other, particularly lower resourced settings.     

Assessing the utilization of maternal and child health care among married adolescent women: evidence from India

This study explores the prevalence and factors associated with the utilization of maternal and child health care services among married adolescent women in India using the third round of the National Family Health Survey (2005-06). The findings suggest that the utilization of maternal and child health care services among adolescent women is far from satisfactory in India. A little over 10% of adolescent women utilized antenatal care, about 50% utilized safe delivery services and about 41% of the children of adolescent women received full immunization. Large differences by urban-rural residence, educational attainment, religion, economic status and region were evident. Both gross effect and fixed effect binary logit models yielded statistically significant socioeconomic and demographic factors. Women's education, wealth quintile and region are the most important determinants for the utilization of maternal and child health care services. Health care programmes should focus more on educating adolescents, providing financial support, creating awareness and counselling households with married adolescent women. Moreover, there should be substantial financial assistance for the provision of delivery and child care for married women below the age of 19 years.     

Socioeconomic Disparities in the Prevalence of Blepharoptosis in the South Korean Adult Population Based on a Nationwide Cross-Sectional Study

Purpose

We investigated the association between socioeconomic status (SES) and the prevalence of blepharoptosis in a representative South Korean population.

Methods

This cross-sectional study was based on data obtained in the Korea National Health and Nutrition Examination Survey from 2010 to 2012. In total, 17,178 Korean adults (7,261 men and 9,917 women) aged 19 years or older were enrolled. Blepharoptosis was defined as a marginal reflex distance 1 (MDR 1) lower than 2 mm. Household income and education level were used as indicators of SES. Univariate and multiple logistic regression analyses were conducted to analyze the relationship between SES and the prevalence of blepharoptosis.

Results

Household income was inversely associated with the prevalence of blepharoptosis in women [adjusted odds ratio (aOR) and corresponding 95% confidence interval (95% CI) was 1.894 (1.336, 2.685)], and educational level was inversely associated with blepharoptosis in both men and women [aORs and 95% CIs were 1.572 (1.113, 2.219) and 1.973 (1.153, 3.376), respectively]. After adjusting for household income and educational level, low SES was associated with a high prevalence of blepharoptosis in women only.

Conclusions

Socioeconomic disparities in the prevalence of blepharoptosis were found among women. Indeed, future research using a prospective design to determine the causal relationship between SES and blepharoptosis may identify SES as a risk factor for this condition.     

Variation in the relationship between BMI and survival by socioeconomic status in Great Britain

We investigate the relationship between obesity and survival, and the extent to which this relationship varies by socioeconomic status (SES). The underlying model is based on the “Pathways to health” framework in which SES affects health by modifying the relationship between lifestyles and health. We use data from the British Health and Lifestyle Survey (1984–1985) and the longitudinal follow-up in June 2009, and run parametric Gompertz survival models to investigate the association between obesity and survival, also accounting for interactions between obesity and both age and SES. Generally we find that obesity is negatively associated with survival, and that SES is positively associated with survival, in both men and women. The interactions between obesity and SES predict survival among women but not among men. Obesity compared with normal weight is associated with a reduction in survival of 3.3, 3.2 and 2.8 years in men aged 40, 50 and 60 years, respectively. Corresponding numbers among women in the lowest SES group are 13.1, 9.7 and 6.1 years, respectively; in the highest SES group they are 6.2, 3.1 and 0.1 years, respectively, a difference of approximately 6 years between the highest and lowest SES groups.     

Trends in the Association between Obesity and Socioeconomic Status in U.S. Adults: 1971 to 2000

Objective: To study the secular trends in the disparity of obesity across socioeconomic status (SES) groups among U.S. adults. Research Methods and Procedures: We used national representative data collected in the National Health and Nutrition Examination Surveys conducted in 1971 to 1974, 1976 to 1980, 1988 to 1994, and 1999 to 2000 from 28, 543 adults 20 to 60 years old. Obesity was defined based on BMI calculated using measured weight and height. Trends in the relationship between obesity and education levels were analyzed controlling for age, gender, and ethnicity. Results: The disparity in obesity across SES (less than high school, high school, and college or above to indicate low, medium, and high SES, respectively) has decreased over the past 3 decades. In National Health and Nutrition Examination Surveys I (1971 to 1974), there was as much as a 50% relative difference in the obesity prevalence across the three groups, but by 1999 to 2000, it decreased to 14%. This trend was more pronounced in women. The trends of diminishing disparities in obesity were also revealed by our logistic and linear regression analyses. The odds ratio converged to 1 from the 1970s to 2000. In most sociodemographic groups, the relationship between BMI and SES (coefficients) has been weakened over time. Discussion: The association between SES and obesity has been weakened over the past 3 decades, when the prevalence of obesity increased dramatically. There are considerable variations in the changes in the associations across gender and ethnic groups. Our findings suggest that individual characteristics are not likely the main cause of the current obesity epidemic in the U.S., whereas social‐environmental factors play an important role. Strategies for obesity prevention and management should target all SES groups from a societal perspective.     

Changes in Health between Ages 54 and 65: The Role of Job Characteristics and Socioeconomic Status

We model the relationships between socioeconomic status (SES), the conditions of paid employment, and changes between ages 54 and 65 in a variety of health outcomes: self-reported overall health, musculoskeletal health, and depression. To what extent is SES associated with changes in these health outcomes net of the conditions of paid employment? At the same time, to what extent are the conditions of paid employment independently associated with these outcomes net of SES? To address these questions we use unique data collected from a single cohort of men and women to model changes in these health outcomes between ages 54 and 65. Although results vary across outcomes, it is clear that there are some circumstances in which associations between SES and changes in health can be (at least partly) attributed to working conditions, and that there are other circumstances in which associations between working conditions and changes in health can be (at least partly) attributed to SES. We conclude that the largely disconnected literatures on health disparities (in the social sciences and public health) and job design (in occupational stress and ergonomics) could and should be fruitfully connected.     

Racial/Ethnic Disparities in Obesity Among US‐born and Foreign‐born Adults by Sex and Education

This study examines sex and education variations in obesity among US‐ and foreign‐born whites, blacks, and Hispanics utilizing 1997–2005 data from the National Health Interview Survey on 267,585 adults aged ≥18 years. After adjusting for various demographic, health, and socioeconomic factors via logistic regression, foreign‐born black men had the lowest odds for obesity relative to US‐born white men. The largest racial/ethnic disparity in obesity was between US‐born black and white women. High educational attainment diminished the US‐born black–white and Hispanic–white disparities among women, increased these disparities among men, and had minimal effect on foreign‐born Hispanic–white disparities among women and men. Comprehension of these relationships is vital for conducting effective obesity research and interventions within an increasingly diverse United States.     

Birthweight outcomes in Bolivia: The role of maternal height,ethnicity, and behavior

We identify maternal behavioral factors associated with birthweight in Bolivia using data from the Demographic and Health Survey (DHS) of 2003. We estimate birthweight as a function of maternal behavior and the child's sex and gestational age. We control for maternal height, ethnicity, education, and wealth, and for differences observed across Bolivian regions in educational and health outcomes, demographic indicators, and altitude. We find that maternal age, fertility record, and birth spacing behavior are the main observable behavioral factors associated with birthweight, and that maternal height is associated with gestational age, a main determinant of birthweight. We also find that after controlling for gestational age, both ethnicity and altitude have an insignificant effect on birthweight.     

Examining the effect of household wealth and migration status on safe delivery care in urban India, 1992-2006

Background

Although the urban health issue has been of long-standing interest to public health researchers, majority of the studies have looked upon the urban poor and migrants as distinct subgroups. Another concern is, whether being poor and at the same time migrant leads to a double disadvantage in the utilization of maternal health services? This study aims to examine the trends and factors that affect safe delivery care utilization among the migrants and the poor in urban India.

Methodology/Principal Findings

Using data from the National Family Health Survey, 1992–93 and 2005–06, this study grouped the household wealth and migration status into four distinct categories poor-migrant, poor-non migrant, non poor-migrant, non poor-non migrant. Both chi-square test and binary logistic regression were performed to examine the influence of household wealth and migration status on safe delivery care utilization among women who had experienced a birth in the four years preceding the survey. Results suggest a decline in safe delivery care among poor-migrant women during 1992–2006. The present study identifies two distinct groups in terms of safe delivery care utilization in urban India – one for poor-migrant and one for non poor-non migrants. While poor-migrant women were most vulnerable, non poor-non migrant women were the highest users of safe delivery care.

Conclusion

This study reiterates the inequality that underlies the utilization of maternal healthcare services not only by the urban poor but also by poor-migrant women, who deserve special attention. The ongoing programmatic efforts under the National Urban Health Mission should start focusing on the poorest of the poor groups such as poor-migrant women. Importantly, there should be continuous evaluation to examine the progress among target groups within urban areas.     

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

Background

In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.

Methodology/Principal Findings

We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended.

Conclusions

In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.