Gender transformative approaches in mHealth for maternal healthcare in sub-Saharan Africa: a systematic review.

Background: This review focuses on studies about digital health interventions in sub-Saharan Africa. Digital health interventions in sub-Saharan Africa are increasingly adopting gender-transformative approaches to address factors that derail women's access to maternal healthcare services. However, there remains a paucity of synthesized evidence on gender-transformative digital health programs for maternal healthcare and the corresponding research, program and policy implications. Therefore, this systematic review aims to synthesize evidence of approaches to transformative gender integration in digital health programs (specifically mHealth) for maternal health in sub-Saharan Africa. Method: The following key terms "mobile health", "gender", "maternal health", "sub-Saharan Africa" were used to conduct electronic searches in the following databases: PsycInfo, EMBASE, Medline (OVID), CINAHL, and Global Health databases. The method and results are reported as consistent with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data synthesis followed a convergent approach for mixed-method systematic review recommended by the JBI (Joanna Briggs Institute). Results: Of the 394 studies retrieved from the databases, 11 were included in the review. Out of these, six studies were qualitative in nature, three were randomized control trials, and two were mixed-method studies. Findings show that gender transformative programs addressed one or more of the following categories: (1) gender norms/roles/relations, (2) women's specific needs, (3) causes of gender-based health inequities, (4) ways to transform harmful gender norms, (5) promoting gender equality, (6) progressive changes in power relationships between women and men. The most common mHealth delivery system was text messages via short message service on mobile phones. The majority of mHealth programs for maternal healthcare were focused on reducing unintended pregnancies through the promotion of contraceptive use. The most employed gender transformative approach was a focus on women's specific needs. Conclusion: Findings from gender transformative mHealth programs indicate positive results overall. Those reporting negative results indicated the need for a more explicit focus on gender in mHealth programs. Highlighting gender transformative approaches adds to discussions on how best to promote mHealth for maternal health through a gender transformative lens and provides evidence relevant to policy and research. Systematic review registration: PROSPERO CRD42023346631.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study.

INTRODUCTION: In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system. METHODS: We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation. RESULTS: The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges. CONCLUSION: This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

Seeking maternal health care in rural Nigeria: through the lens of negofeminism.

BACKGROUND: Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. METHOD: This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis. RESULTS: Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions. CONCLUSION: This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness.

Texting for life: a mobile phone application to connect pregnant women with emergency transport and obstetric care in rural Nigeria.

BACKGROUND: Difficulty in transportation to access skilled providers has been cited repeatedly as a major barrier to utilization of emergency obstetric care in Nigeria. OBJECTIVE: The objective of this paper is to describe the design, implementation, and outcomes of a mobile phone technology aimed at rapidly reaching rural Nigerian women who experience pregnancy complications with emergency transportation and access to providers. METHOD: The project was implemented in 20 communities in two predominantly rural Local Government Areas (LGAs) of Edo State, in southern Nigeria, as part of a larger implementation project aimed at improving the access of rural women to skilled pregnancy care. The digital health innovation named Text4Life, allowed women to send a brief message from their mobile phone to a server linked to Primary Health Care (PHC) facilities and to access pre-registered transport owners. Pregnant women were registered and taught to text short messages to a server from their mobile phones or those of a friend or relative when they experience complications. RESULTS: Over 18 months, 56 women out of 1620 registered women (3.5%) texted the server requesting emergency transportation. Of this number, 51 were successfully transported to the PHC facilities, 46 were successfully treated at the PHC, and five were referred to higher-level care facilities. No maternal deaths occurred during the period, while four perinatal deaths were recorded. CONCLUSION: We conclude that a rapid short message sent from a mobile phone to a central server and connected to transport providers and health facility managers is effective in increasing the access of pregnant women to skilled emergency obstetric services in rural Nigeria.

Understanding gender dynamics in mHealth interventions can enhance the sustainability of benefits of digital technology for maternal healthcare in rural Nigeria.

Introduction: Nigeria faces enormous challenges to meet the growing demands for maternal healthcare. This has necessitated the need for digital technologies such as mobile health, to supplement existing maternal healthcare services. However, mobile health programs are tempered with gender blind spots that continue to push women and girls to the margins of society. Failure to address underlying gender inequalities and unintended consequences of mobile health programs limits its benefits and ultimately its sustainability. The importance of understanding existing gender dynamics in mobile health interventions for maternal health cannot be overstated. Objective: This study explores the gender dimensions of Text4Life, a mobile health intervention for maternal healthcare in Edo State, Nigeria by capturing the unique perspectives of women who are the primary beneficiaries, their spouses who are all men, and community leaders who oversaw the implementation and delivery of the intervention. Method: This qualitative study used criterion-based purposive sampling to recruit a total of 66 participants: 39 women, 25 men, and two ward development committee chairpersons. Data collection involved 8 age and sex desegregated focus group discussions with women and men and in-depth interviews with ward development committee chairpersons in English or Pidgin English. Translated and transcribed data were exported to NVivo 1.6 and data analysis followed a conventional approach to thematic analysis. Results: Women had some of the necessary resources to participate in the Text4Life program, but they were generally insufficient thereby derailing their participation. The program enhanced women's status and decision-making capacity but with men positioned as heads of households and major decision-makers in maternal healthcare, there remained the possibility of deprioritizing maternal healthcare. Finally, while Text4Life prioritized women's safety in various contexts, it entrenched systems of power that allow men's control over women's reproductive lives. Conclusion: As communities across sub-Saharan Africa continue to leverage the use of mHealth for maternal health, this study provides insights into the gender implications of women's use of mHealth technologies. While mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's access to resources and their reproductive and social lives.

Exploring underutilization of skilled maternal healthcare in rural Edo, Nigeria: A qualitative study.

INTRODUCTION: Existing studies have acknowledged the underutilization of skilled maternal healthcare services among women in rural Nigeria. Consequently, women in rural areas face a disproportionate risk of poor health outcomes including maternal morbidity and mortality. Addressing the challenge of non-use of skilled maternal healthcare in rural areas necessitates the involvement of multi-stakeholders across different sectors who have vital roles to play in improving maternal health. This study explores the factors contributing to the non-use of maternal healthcare services in rural areas of Edo, Nigeria from the perspectives of community elders and policymakers. METHODS: In this qualitative study, data were collected through 10 community conversations (group discussions) with community elders each consisting of 12 to 21 participants, and six key informant interviews with policymakers in rural areas of Edo State, Nigeria. Participants were purposefully selected. Conversations and interviews occurred in English, Pidgin English and the local language; lasted for an average of 9 minutes; were audio-recorded and transcribed to English. Data were manually coded, and data analysis followed the analytical strategies for qualitative description including an iterative process of inductive and deductive approaches. RESULTS: Policymakers and community elders attributed the non-use of maternal health services to poor quality of care. Notions of poor quality of care included shortages in skilled healthcare workers, apathy and abusive behaviours from healthcare providers, lack of life-saving equipment, and lack of safe skilled pregnancy care. Non-use was also attributed to women's complex utilization patterns which involved a combination of different types of healthcare services, including traditional care. Participants also identified affordability and accessibility factors as deterrents to women's use of skilled maternal healthcare. CONCLUSION: The emerging findings on pregnant women's combined use of different types of care highlight the need to improve the quality, availability, accessibility, and affordability of skilled maternal care for rural women in Nigeria.

Leaving no woman or girl behind? Inclusion and participation in digital maternal health programs in sub-Saharan Africa.

Across sub-Saharan Africa where access to adequate maternal healthcare is fraught with myriad challenges, especially for hard-to-reach populations, digital health technologies offer opportunities to improve maternal health outcomes. Digital health can circumvent inefficiencies in the traditional healthcare system and address challenges such as limited access to in-person medical consultations, and poor access to skilled birth attendants and health promotion activities. These benefits notwithstanding, digital health can be exclusionary. Too often, digital maternal health programs are not designed with a focus on equity in distribution nor are they designed from a gender equity standpoint. In this paper, we illustrate exclusionary practices of digital health programs through an extensive literature review of digital maternal health programs across sub-Saharan Africa. Taking an intersectional approach, we discuss how women are most vulnerable and excluded at the intersection of gender, literacy, and disability. Tackling exclusionary practices in digital health is crucial to ensure that no woman or girl is left behind.

Enablers and barriers to the acceptability of mHealth for maternal healthcare in rural Edo, Nigeria.

Objective: Acceptability has become a key consideration in designing, implementing and evaluating digital health interventions. Current evidence points to acceptability as a crucial factor in sustaining mobile health programs for maternal health across sub-Saharan Africa particularly in Nigeria where the burden of maternal mortality is high. This paper describes the enablers and barriers to the acceptance of Text4Life, a mobile phone-based health intervention that extends maternal healthcare services to rural areas of Edo State Nigeria. Method: This is a cross-sectional qualitative study of women who used Text4Life, their spouses who were all men and Ward Development Committee chairpersons who oversaw the implementation of Text4Life. This study was set in Etsako East and Esan Central Local Government Areas of Edo State, Nigeria. Between September 2021 and January 2022, eight focus groups were conducted with 64 participants: 39 women and 25 men. Two in-depth interviews were conducted with Ward Development Committee chairpersons. Data collection was conducted in English and Pidgin English. Discussions and interviews were digitally recorded and translated to English from Pidgin English where necessary. Data analysis followed a mainly deductive approach to thematic analysis, however, emergent information from the data was also considered and reported. Results: The results show that participants' positive attitudes towards the intervention, the involvement of the community, participants' understanding of the intervention, and perceived effectiveness of the Text4Life program were enablers to women's acceptance of Text4Life and enablers to Ward Development Committee chairpersons' assistance with the program. On the other hand, limited resources and a clash with the community's value system presented barriers to the acceptability of the Text4Life program. Conclusion: Our findings demonstrate the importance of alleviating the burdens associated with participating in mobile health interventions while noting that the risk of obstructing the gains from mobile health interventions is high if plans for sustaining it are not incorporated early enough in the design phase.

"We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria.

OBJECTIVE: The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria. DESIGN: This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. SETTING: The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. PARTICIPANTS: The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. RESULTS: Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. CONCLUSION: This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria.

BACKGROUND: The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country's very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women's access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women's use of skilled pregnancy care in rural Edo State, Nigeria. METHODS: This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches. RESULTS: Stakeholders identified barriers to pregnant women's use of skilled pregnancy care and they include; financial constraints, women's lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women's use of skilled pregnancy care. CONCLUSIONS: This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women's health behaviour. Therefore, initiatives seeking to improve pregnant women's use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

Men's perception of barriers to women's use and access of skilled pregnancy care in rural Nigeria: a qualitative study.

BACKGROUND: Greater paternal engagement is positively associated with improved access to and utilization of maternal services. Despite evidence that male involvement increased uptake of maternal and child services, studies show that few men are participating in MNCH programs. Community leaders have long been engaged in public health promotion in rural settings and have been shown to mobilize communities to enhance changes in cultural practices related to public health. With the ultimate goal of increasing men's involvement in maternal health, this study seeks to understand men's perceptions of community and health systems barriers to maternal access and usage of skilled care in rural Edo, Nigeria. METHODS: This qualitative study involved the analysis of data collected from community conversations with male elders in Etsako East and Esan South East Local Government Areas of Edo State, Nigeria. Community conversations participants (n = 128) comprised of elders between the ages of 50-101. A total of 9 community conversations were conducted. Discussions were audio recorded, transcribed and imported into Atlas.ti 6.2 for content analysis. RESULTS: Men's perceptions of barriers to maternal use of skilled care are presented in two overarching themes: community systems and health systems. Three sub themes were generated as community systems barriers to maternal healthcare use, they include: gender roles, traditional treatment and policy changes. Three sub themes emerged under health system barriers and they include: cost of health facilities, dissatisfaction with facilities and distance from facilities. CONCLUSION: Findings suggest that community elders are not only in a good position to influence men's behavior, they are also a source of information to policy makers on strategies to overcome barriers to maternal health, especially at the community level. Furthermore, community elders need support to enact regulations that will promote men's involvement in maternal health, thereby increasing maternal use of skilled care.

Knowledge and attitude of HIV/AIDS among women in Nigeria: a cross-sectional study.

Background: The Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) epidemic is one of the world's most serious public health and social problems. Promoting knowledge and attitude towards HIV/AIDS is a key strategy to control the prevalence of this growing epidemic. This study aimed to measure knowledge and attitude about HIV/AIDS along with the factors of association Nigerian women. Methods: This is a cross-sectional study based on data from the 2013 Demographic Health Survey (DHS) conducted among community dwelling women in Nigeria. A set of 13 questions was identified relevant to knowledge and attitude about HIV/AIDS. Each correct answer was scored as 1 and wrong answer as '0'. Normality of the variables was examined using Shapiro-Wilks tests. The socioeconomic and community factors associated with HIV/AIDS knowledge and attitude were examined by linear regression with dummy variables model. Results: Means score (SD) on knowledge of transmission was 6.4 (2.0) and that for attitude was 2.1 (1.2). In the regression models, knowledge and attitude of HIV/AIDS were positively associated with survey years and respondents' age; geographical region was significantly associated with HIV/AIDS knowledge and attitude; rural respondents had significant reduction in knowledge [Exp(B)=0.86; 95% confidence interval (CI)=0.83-0.89] and positive attitude to HIV/AIDS [Exp(B)=0.91; 95% CI=0.89-0.93] compared with the urban counterpart, respectively. Conclusion: Findings of the present study suggested that women's knowledge and attitude about HIV/AIDS in Nigeria needs more attention to attain the global target to end its epidemics and other communicable diseases by 2030.

Improving Water, Sanitation and Hygiene Practices, and Housing Quality to Prevent Diarrhea among Under-Five Children in Nigeria.

Sub-Saharan Africa as a region accounts for the bulk of the global under-five mortality rate, to which diarrhea is major contributor. Millions of children die from diarrheal diseases each year and those who survive often do so facing suboptimal growth. Preventing the common pathways of transmission for diarrhea-causing pathogens, including improved water, sanitation, and hygiene (WASH) are regarded as the most cost-effective measures for tackling this life-threatening disease. This study aimed to quantitatively assess the quality of living arrangement and access to WASH, and their impact on diarrheal outcomes among under-five children in Nigeria. Methods: Data were collected from the 2013 Nigeria Demographic and Health survey (NDHS). Study participants included 28,596 mother-child pairs. Household construction material for wall, floor, and ceiling, access to electricity, and improved water and toilet, were included as the main explanatory variables. Data were analyzed using descriptive and multivariable regression methods. Results: The prevalence of diarrhea was 11.3% (95% CI = 10.2⁻12.6), with the rate being markedly higher in rural (67.3%) as compared to urban areas (32.7%). In the regression analysis, lacking access to improved toilet and water facilities were associated with 14% and 16% higher odds, respectively, of suffering from diarrhea as compared to those who had improved access. Conclusion: There is evidence of a weak, but statistically significant, relationship between the quality of living environment, including water and sanitation facilities, and diarrhea among under-five children in Nigeria. The study concludes that investing in living conditions and WASH may have potential benefits for child mortality prevention programs in the country.

Prevalence and determinants of terminated and unintended pregnancies among married women: analysis of pooled cross-sectional surveys in Nigeria.

BACKGROUND: Induced pregnancy termination and unintended pregnancy are two commonly occurring phenomena in the discipline of women's reproductive health. In the present study, we explored cross-sectional data pooled from three rounds of Nigeria Demographic and Health Survey (NDHS) to understand the trends of prevalence of pregnancy termination and unintended pregnancy as well as the interplay of various sociodemographic and economic factors whereby these health issues occur. METHODS: Study participants were 79 825 currently married women aged 15-49 years. Data were collected from NDHS conducted in 2003, 2008 and 2013. Outcome variables were self-reported history of pregnancy termination and unintended pregnancy for the last birth. Data were analysed using descriptive and multivariable logistic regression methods. RESULTS: Mean (±SD) age of the respondents was 28.7 years (±9.6). The overall prevalence of pregnancy termination and unintended pregnancy were about 11%. Older women had increase in the odds of terminated pregnancies, compared with women aged 15-19 years, while the converse was true for unintended pregnancy in the adjusted model. Educated women had significant higher odds of terminated and unintended pregnancies compared with women with no formal education. Women with higher wealth index were more likely to have unintended and terminated pregnancies after adjusting for other covariates. Remarkably, women who had unintended pregnancy were 1.47 times as likely to have terminated pregnancy compared with those who had no unintended pregnancy (OR=1.47; 95% CI 1.30 to 1.65). Experience of intimate partner violence had significant association with terminated and unintended pregnancies. CONCLUSION: The findings of this study showed that unintended and terminated pregnancies remain part of the issues to be addressed if the goal of ensuring healthy lives and promoting the well-being for all at all ages must be met. Stakeholders in Nigerian healthcare system should protect the lives of women who are vulnerable to the fatal consequences of unsafe abortion, especially in cases of rape, sexual assault, incest and where continuing a pregnancy would endanger the lives of women.

Factors associated with maternal utilization of health facilities for delivery in Ethiopia.

Background: As a signatory of the Millennium Development Goals, Ethiopia has made significant achievements towards meeting the maternal mortality related goals since 1990. Despite that, the country is still experiencing unacceptably high maternal mortality rates, and challenges to improving the coverage and utilisation of health facility delivery services which represent a key strategy to combat maternal mortality. Currently, there is limited evidence on the factors associated with health facility delivery in Ethiopia. Therefore, the objective of this study was to identify the correlates of facility delivery among urban and rural women in Ethiopia. Methods: This was a cross-sectional study based on data from the 2011 Ethiopian Demographic and Health Survey. Participants were 7540 women aged between 15 and 49 years with a history of at least one birth. The outcome variable was place of delivery. Data were analyzed using bivariate and multivariable regression techniques. Results: The overall prevalence of health facility delivery was 17.1% (1447/7540). In the multivariable regression analysis, education, wealth status, frequency of antenatal care visits and mother's age at first birth were found to be significantly associated with women's choice of place of delivery. Among urban women, those who had primary and secondary/higher level education had increased odds of delivering at a health facility compared with those without formal education. Those who were from the richest households had higher odds of delivering at a health facility compared with those in the lowest class. In urban and rural areas, compared with those who had no ANC visits, those who had at least four visits also had increased odds of delivering at a health facility. In the urban areas, those who were over 18 years old at their first childbirth had significantly higher odds of choosing to deliver at a health facility. Conclusion: Findings show that the prevalence of healthy facility delivery in Ethiopia is remarkably low. Addressing the sociodemographic and wealth inequities can help promote the utilisation of facility delivery in both urban and rural areas. Policy-makers should consider improving access to education as a strategy to meet maternal health related goals and treat education as a multipronged strategy. Providing free healthcare access could be one strategy to achieve the universal coverage of essential maternal healthcare services.

Urban-rural difference in satisfaction with primary healthcare services in Ghana.

BACKGROUND: Understanding regional variation in patient satisfaction about healthcare systems (PHCs) on the quality of services provided is instrumental to improving quality and developing a patient-centered healthcare system by making it more responsive especially to the cultural aspects of health demands of a population. Reaching to the innovative National Health Insurance Scheme (NHIS) in Ghana, surpassing several reforms in healthcare financing has been a milestone. However, the focus of NHIS is on the demand side of healthcare delivery. Studies focusing on the supply side of healthcare delivery, particularly the quality of service as perceived by the consumers are required. A growing number of studies have focused on regional differences of patient satisfaction in developed countries, however little research has been conducted concerning patient satisfaction in resource-poor settings like in Ghana. This study was therefore dedicated to examining the variation in satisfaction across rural and urban women in Ghana. METHODS: Data for the present study were obtained from the latest demographic and health survey in Ghana (GDHS 2014). Participants were 3576 women aged between 15 and 49 years living in non-institutional settings in Ghana. Summary statistics in percentages was used to present respondents' demographic, socioeconomic characteristics. Chi-square test was used to find association between urban-rural differentials with socio-economic variables. Multiple logistic regression was performed to measure the association of being satisfied with primary healthcare services with study variables. Model fitness was tested by pseudo R 2. Statistical significance was set at p < 0.05. RESULTS: The findings in this study revealed that about 57.1% were satisfied with primary health care services. The urban and rural areas reported 57.6 and 56.6% respectively which showed no statistically significant difference (z = 0.64; p = 0.523; 95%CI: -0.022, 0.043). Bivariate analysis showed that region, highest level of education, wealth index and type of facility were significantly associated with location of residence (urban-rural areas). After adjusting for confounding variables using logistic regression, geographical location became a key factor of satisfaction with primary healthcare services by location of residence. In urban areas, respondents from Greater Accra had 64% increase in the level of satisfaction when compared to those in Western region (OR = 1.64; 95CI: 1.09-2.47), Upper East had 75% increase in satisfaction compared to Western region (OR = 1.75; 95%CI: 1.08-2.84), Northern had an estimated 44% reduction in satisfaction when compared to Western region (OR = 0.56; 95%CI: 0.34-0.92). However, rural areas in Central, Volta, Eastern, Ashanti, Brong Aghafo, Northern and Upper West region had 51, 81, 69, 46, 62, 75 and 61% reduction respectively in the level of satisfaction when compared to Western region. CONCLUSIONS: Patient satisfaction is an important indicator of health outcomes. Quality of care and measuring level of patient satisfaction has been found to be the most useful tool to predict utilization and compliance. In fact, satisfied patients are more likely than unsatisfied ones to continue using health care services. Our results suggest that policymakers need to better understand the determinants of satisfaction with the health system and how different socio-demographic groups perceive satisfaction with healthcare services so as to address health inequalities between urban and rural areas within the same country.

Timing and adequate attendance of antenatal care visits among women in Ethiopia.

INTRODUCTION: Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia. METHODS: Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population. RESULTS: Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed initiation of ANC visits (OR = 1.65; 95%CI: 1.26-2.18). However, rural women had 44% reduction in the odds of having inadequate ANC visits. In addition, multi-parity showed higher odds of delayed initiation of ANC visit when compared to the primigravida (OR = 2.20; 95%CI: 1.07-2.69). On the contrary, there was 36% reduction in the odds of multigravida having inadequate ANC visits when compared to the women who were primigravida. There were higher odds of inadequacy in ANC visits among women who engaged in sales/business, agriculture, skilled manual and other jobs when compared to women who currently do not work, after adjusting for covariates. From the predictive margins, assuming the distribution of all covariates remained the same among respondents, but everyone was aged 15-19 years, we would expect 71.8% delayed initiation of ANC visit. If everyone was aged 20-24years, 73.4%; 25-29years, 66.5%; 30-34years, 64.8%; 35-39years, 65.6%; 40-44years, 59.6% and 45-49years, we would expect 70.1% delayed initiation of ANC visit. If instead the distribution of age was as observed and for other covariates remained the same among respondents, but no respondent lived in the rural, we would expect about 61.4% delayed initiation of ANC visit; if however, everyone lived in the rural, and we would expect 71.6% delayed initiation in ANC visit. Model III revealed the predictive margins of all factors examined for delayed initiation for ANC visits, while Model IV presented the predictive marginal effects of the determinants of adequacy of ANC visits. CONCLUSION: The precise mechanism by which these factors affect ANC visits remain blurred at best. There may be factors on the demand side like the women's empowerment, financial support of the husband, knowledge of ANC visits in the context of timing, frequency and the expectations of ANC visits might be mediating the effects through the factors found associated in this study. Supply side factors like the quality of ANC services, skilled staff, and geographic location of the health centers also mediate their effects through the highlighted factors. Irrespective of the knowledge about the precise mechanism of action, policy makers could focus on improving women's empowerment, improving women's education, reducing wealth inequity and facilitating improved utilization of ANC through modifications on the supply side factors such as geographic location and focus on hard to reach women.

Women's decision-making autonomy and utilisation of maternal healthcare services: results from the Bangladesh Demographic and Health Survey.

OBJECTIVES: The aim of this study was to determine the association between women's decision-making power and utilisation of maternal healthcare services (MHS) among Bangladeshi women. SETTINGS: This is a nationally representative survey that encompassed Dhaka, Rajshahi, Rangpur, Chittagong, Khulna, Barisal and Sylhet in Bangladesh. Sample households were selected by a two-stage stratification technique. First, 207 clusters in urban areas and 393 in rural areas were selected for 600 enumeration areas with proportional probability. In the second stage, on average 30 households were selected systematically from the enumeration areas. Finally, 17 989 households were selected for the survey of which 96% were interviewed successfully. PARTICIPANTS: Cross-sectional data on 4309 non-pregnant women were collected from Bangladesh demographic and health survey 2014. Decision-making status on respondent's own healthcare, large household purchases, having a say on child's healthcare and visiting to family or relatives were included in the analysis. RESULTS: Prevalence of at least four antenatal attendance, facility delivery and postnatal check-up were respectively 32.6% (95% CI 31.2 to 34), 40.6% (95% CI 39.13 to 42.07) and 66.3% (95% CI 64.89 to 67.71). Compared with women who could make decisions alone, women in the urban areas who had to decide on their healthcare with husband/partner had 20% (95% CI 0.794 to 1.799) higher odds of attending at least four antenatal visits and those in rural areas had 35% (95% CI 0.464 to 0.897) lower odds of attending at least four antenatal visits. Women in urban and rural areas had respectively 43% (95% CI 0.941 to 2.169) and 28% (95% CI 0.928 to 1.751) higher odds of receiving postnatal check-up when their health decisions were made jointly with their husband/partner. CONCLUSION: Neither making decisions alone, nor deciding jointly with husband/partner was always positively associated with the utilisation of all three types of MHS. This study concludes that better spousal cooperation on household and health issues could lead to higher utilisation of MHS services.

Knowledge of prevention, cause, symptom and practices of malaria among women in Burkina Faso.

BACKGROUND: Malaria remains a major public health issue in most southern African countries as the disease remains hyper endemic. Burkina Faso continues to face challenges in the treatment of malaria, as the utilization of preventive measures remains low on a national scale. While it has been acknowledged that understanding women's health-seeking behaviours, perception of malaria and its preventive measures will aid in the control of malaria, there is paucity of information on Knowledge, Attitudes and Practices among women in the reproductive age of 15-49 years in Burkina Faso. This study investigated women's knowledge of malaria, attitudes towards malaria, and practices of malaria control in order to create a synergy between community efforts and governmental/non-governmental malaria control interventions in Burkina Faso. METHODS: The analysis used data from the 2014 Burkina Faso Malaria Indicator Survey (MIS). In total 8111 women aged between 15-49 years were included in the present study. We assessed women's knowledge about 1) preventive measures, 2) causes and 3) symptoms of malaria, as well as malaria prevention practices for their children and during pregnancy. The socio-demographic characteristics were considered for Age, Religion, Education, Wealth index, Number of household members, Sex of household head, Household possession of radio, TV and Received antenatal care. Data were analyzed using STATA, version 14. Associations between variables were tested using a Chi-square and logistic regression, with the level of statistical significance set at 95%. RESULTS: A preponderant proportion of respondents were aged 15-29 years (mean age was 28.63±9.41). About three-quarters of the respondents had no formal education. An estimated two-third of the participants were of Islamic faith, while access to media and behavioural communication were generally poor. The level of knowledge was 53% for rural women and 68.2% for urban dwellers. In sum, there was 56.1% level of accurate knowledge of malaria among women in Burkina Faso. In the multivariable logistic regression, women in rural location had 40% reduction in the odds of having accurate knowledge of malaria when compared to urban women (aOR = 0.60; 95%CI: 0.52-0.68). The educational level was a key factor in the knowledge of malaria. The odds of having accurate knowledge of malaria increased as the educational level increased, hence, women with secondary and higher education had 29% and 93% increase in the odds of having accurate knowledge of malaria when compared to the women without formal education. Results indicate that antenatal care (ANC) services were major sources of information on malaria. Women who reportedly received ANC were 3.9 times more likely to have accurate knowledge of malaria when compared to those who did not utilize skilled ANC services (aOR = 3.90; 95%CI = 3.34-4.56). CONCLUSION: The overall knowledge of malaria prevention practices among a large proportion of women was found to be low, which implies that the knowledge about the prevention of malaria should be improved upon by both urban and rural dwellers. There is need for concerted behavioural communication intervention to improve the knowledge of malaria especially for rural dwellers regarding malaria prevention measures, causes and symptoms. Consistent efforts at providing relevant information by health organizations are needed to reduce and control incidences of malaria in the general public.