A Systematic Appraisal of the Factors Influencing Antenatal Services and

Delivery Care in Sub-Saharan Africa

Nancy Innocentia Ebu University of Cape Coast School of Nursing, Ghana

Commonwealth Nurses Conference March, 2014 –Royal College of Physicians, London

Acknowledgement

• Authors of all the literature I used

• University of Cape Coast

• Organizers of the event

Background

• Maternal mortality is an issue of global health concern

• In 2012, United Nations report indicated that 287,000 women died due to pregnancy, delivery and postnatal causes

Background • 56% of the cases occurring in Sub-Saharan Africa • 29 percent in Southern Asia in 2010, and accounting

for a total of 245,000 maternal deaths (United Nations, 2012)

• Millennium Development Goal (MDG) five • Countries are expected to make progress towards

meeting the target by 2015

Background

• The World Health Organisation (WHO) has recommended at least four ANC visits for pregnant women (WHO, 2010)

• The proportion of women who had enough

ANC visits had seen a reduction in Sub-Saharan Africa between 2000 and 2010 (United Nations, 2012)

201020001990

50

49

48

47

46

Year

Perc

ent o

f Att

enda

nts

Fig. 1: Trend Analysis of Utilization of ANC

Background • Many women in the developing world carry

pregnancy to term and deliver without accessing ANC services (Gage and Calixte, 2006)

• Disparities persist in sub-Saharan Africa where maternal death is high due to inadequate access to skilled personnel during delivery (United Nations, 2010)

Purpose of the study

• This systematic appraisal sought to investigate the factors influencing access to antenatal services and delivery care among women of childbearing age in Sub-Saharan Africa

Specific research questions

• What are the different factors influencing access to antenatal services and delivery care in sub-Saharan Africa?

• To what extent does antenatal care influence

hospital delivery?

Methods

• Relevant studies retrieved from CINAHL, MEDLINE, ASSIA, and PUBMED from February to April 2012

• Key words used: antenatal, prenatal, delivery,

care, childbirth, access, utilisation, maternal health

Quality assessment checklist criteria

• Studies published in English • In peer reviewed journals • Since 2001 • Conducted in sub-Saharan

African country • Survey design • Population- Women of

childbearing age 13 - 49 years

• Sampling described • Data collection procedures

described • Data analysis explicit • Results discussed • Ethical issues mentioned • Findings including

information on access to antenatal and delivery care

Included studies Author and Place of Publication

Publication Title Study number

Tann, C. J., Kizza, M., Morison, L., Mabey, D., Muwanga M., Grosskurth, H., Elliott, A.M. (Uganda)

Use of Antenatal Services and Delivery Care in Entebbe, Uganda: A Community Survey. BMC Pregnancy and Childbirth 2007, 7:23

S1

Eijk van, A. M., Bles, H. M., Odhiambo, F., Ayisi, J. G., Blokland, I. E., Rosen, D. H., Adazu, K., Slutsker, L.and Lindblade, A. K. (Kenya)

Use of Antenatal and Delivery Care Among Women in Rural Western Kenya: A Community Based Survey. Reproductive Health 2006, 3:2

S2

Rockers, P. C., Wilson, M. L., Mbaruku, G. Kruk, M. E. (Tanzania)

Source of Antenatal Care Influences Facility Delivery in Rural Tanzania: A Population-Based Study. Maternal Child Health Journal 2008, 13:879-885

S3

Included studies Iyaniwura, C. A. Yussuf, Q. (Nigeria)

Utilisation of Antenatal Care and Delivery Services in Sagamu, South Western Nigeria. African Journal of Reproductive Health 2009, 13:3

S4

Onah, H. E., Ikeako, L. C., Iloabachie, G. C. (Nigeria) 2006

Factors associated with the use of

maternity services in Enugu,

Southern Nigeria. Social Science &

Medicine 2006, 63 :7

S5

Bawa, S. B., Umar, U.S., and Onadeko, M. (Nigeria)

Utilisation of Obstetric Care Services in a Rural Community in South Western Nigeria. African Journal of Medicine and Medical Sciences 2004, 33, 239-244

S6

Data extraction • Names of the authors • Year of publication • Country • Focus of the study

• Methodology issues-

sampling techniques, type of instrument for data collection, whether informed consent was obtained

Outcome measures of interest • Number of antenatal visits • Place of delivery • Level of education • Income • Distance to health facility

Possible sources of bias • Only quantitative studies

• Limited to publications in English

• Further limitation of the publication year to

2001

• Data extraction was conducted by one person

S6(n=100)S5(n=392)S4(n=392)S3(n=1204)S2(n=635)S1(n=413)

100

80

60

40

20

0

Studies and Sample Sizes

Dat

a

% of ANC% of Non-Hospital Deliveries

Variable

Meta Analysis of ANC Attendance and Percentage of Non-Hospital Deliveries

Results

• Results of five studies indicate that 84% to 96% women had at least one ANC visit during pregnancy

• Women with more years of education were

more likely to use ANC services in non government health facility Odds Ratio (OR 3.32, 95% CI 1.84-6.00)

Results • Women with no formal education or fewer

years of education were more likely to seek care from TBA`s (OR=3.07; 95% CI=1.49-6.31)

• Results of four studies showed low use of hospital delivery. One study reported that Christians were more likely to use institutional delivery facilities compared to Moslems and traditional worshippers (p<0.05)

Discussion • Educated women with partners who are highly

educated were likely to use ANC services and is consistent with the results of Charkraborty et al. (2003) Navaneetham and Dharmalingam ( 2002)

• The poor road system and inadequate

transportation opportunities in most rural parts of sub-Saharan Africa are possible barriers to effective healthcare delivery (United Nations, 2010, Titaley, Dibley and Roberts, 2010)

Discussion • Pregnant women in rural communities have greater chances

of delivering in a non health facility assisted by friends and other family relations (Zere et al., 2010)

• Few studies demonstrate a correlation between women of Muslim and the Catholic faith and use of maternity services (Addai, 2000, Overbosch et al., 2004)

• Implementation of free maternal health services by some

governments in the developing world, for instance, Ghana and Nepal have had a positive influence on improving financial barriers to care (Witter et al., 2007)

Implications • Maternal health care - a key priority by all governments

in Sub-Saharan Africa • Higher priority on education of the female child and

women in general • Maternal health policies to remove financial and

physical barriers • Improving the socio-economic environment • Health care providers need to educate women on the

importance of ANC and delivery with skilled personnel • Health care workers need to be more sensitive towards

clients

Conclusion

• Access to ANC services and delivery care are influenced by;

• Women’s and partner’s sociodemographic characteristics,

• Education and economic status, • Distance to health facility, • Quality of care and cost of service

Conclusion

• Access inequalities affect the health of women in sub-Saharan Africa. Promoting safe motherhood would require improving the socioeconomic and political environments that addresses the multiple barriers women encounter

References • Addai, I. (2000) 'Determinants of Use of Maternal-Child Health Services in Rural

Ghana', Journal of Biosocial Science, 32, pp. 1-15 [Online]. Available at: http://journals.cambridge.org (Accessed: 18/4/11)

• Charkraborty, N., Ataharul Islam, M., Chowdhury, I. R., Bari, W. & Akhter, H. H.

(2003) 'Determinants of the Use of Maternal Health Services in Rural Bangladesh', Health Promotion International, 18 (44), pp. 327-337 [Online]. Available at: http://www.swetswise.com (Accessed: 20/3/11)

• Gage, J. A. & Calixte, G. M. (2006) 'Effects of the Physical Accessibility of

Maternal Health Services on their Use in Rural Haiti', Population Studies, 60 (3), pp. 271-288 [Online]. Available at: http://www.jstor.org (Accessed: 3/3/11)

• Navaneetham, K. & Dharmalingam, A. (2002) 'Utilisation of Maternal Care Services in Southern India', Social Science Medicine, 55 (10), pp. 1849-1869 [Online]. Available at: http://www.sciencedirect.com (Accessed: 18/4/11)

References

• Overbosch, G. B., Nsowah-Nuamah, N. N. N., van den Boom, G. J. M. & Damnyag, L. (2004) 'Determinants of Antenatal Care Use in Ghana', Journal of African Economies, 13 (2), pp. 277-301 [Online]. Available at: http://www.sciencedirect.com (Accessed: 18/4/11)

• Titaley, R. C., Dibley, M. J. & Roberts, C. L. (2010) 'Factors Associated with

Underutilisation of Antenatal Care Services in Indonesia: Results of Indonesia Demographic and Health Survey 2002/2003 and 2007', BMC Public Health, 10 (485) [Online]. Available at: http://jr3tv3gd5w.search.serialssolutions.com (Accessed: 2/5/11)

• United Nations (2012) Millennium Development Goals Report.

[Online].Retrieved from: http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf (24/1/2014)

• United Nations (2010) Millennium Development Goals Report. [Online]. Retrieved from: http://www.un.org/millenniumgoals/pdf (Accessed: 20/1/2014)

References • WHO (2010) Trends in Maternal Mortality 1990-2008: A Joint

WHO/UNFPA/World Bank Statement. Geneva: [Online]. Available at: http://whqlibdoc.who.int/publication (Accessed: 20/3/13)

• Witter, S., Arhinful, D. K., Kusi, A. & Zakariah-Akoto, S. (2007) 'The

Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care', Reproductive Health Matters, 15 (30), pp. 61 71 [Online]. Available at: http://www.sciencedirect.com (Accessed: 23/3/11)

• Zere, E., Tumusiime, P., Walker, O., Kirigia, J., Mwikisa, C. & Mbeeli, T. (2010) 'Inequities in Utilisation of Maternal Health Interventions in Namibia: Implications for Progress Towards MDG 5 Target', International Journal for Equity in Health, 9 (16) [Online]. Available at: http://www.equityhealthj.com (Accessed: 21/4/11)

Thank You!