Predictors of Utilisation of Skilled Maternal Healthcare in Lilongwe District, Malawi

Document Type : Original Article

Authors

1 School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi

2 Centre for Social Research, Chancellor College, University of Malawi, Zomba, Malawi

3 Department of Psychology, Maynooth University, Maynooth, Ireland

4 Assisting Living and Learning (ALL) Institute, Maynooth University, Maynooth, Ireland

5 School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland

6 Centre for Rehabilitation Studies, Stellenbosch University, Cape Town, South Africa

7 Olomouc University Social Health Institute, Palacký University, Olomouc, Czech Republic

Abstract

Background
Despite numerous efforts to improve maternal and child health in Malawi, maternal and newborn mortality rates remain very high, with the country having one of the highest maternal mortality ratios globally. The aim of this study was to identify which individual factors best predict utilisation of skilled maternal healthcare in a sample of women residing in Lilongwe district of Malawi. Identifying which of these factors play a significant role in determining utilisation of skilled maternal healthcare is required to inform policies and programming in the interest of achieving increased utilisation of skilled maternal healthcare in Malawi.
 
Methods
This study used secondary data from the Woman’s Questionnaire of the 2010 Malawi Demographic and Health Survey (MDHS). Data was analysed from 1126 women aged between 15 and 49 living in Lilongwe. Multivariate logistic regression was conducted to determine significant predictors of maternal healthcare utilisation.
 
Results
Women’s residence (P = .006), education (P = .004), and wealth (P = .018) were significant predictors of utilisation of maternal healthcare provided by a skilled attendant. Urban women were less likely (odds ratio [OR] = 0.47, P = .006, 95% CI = 0.28–0.81) to utilise a continuum of maternal healthcare from a skilled health attendant compared to rural women. Similarly, women with less education (OR = 0.32, P = .001, 95% CI = 0.16–0.64), and poor women (OR = 0.50, P = .04, 95% CI = 0.26–0.97) were less likely to use a continuum of maternal healthcare from a skilled health attendant.
 
Conclusion
Policies and programmes should aim to increase utilisation of skilled maternal healthcare for women with less education and low-income status. Specifically, emphasis should be placed on promoting education and economic empowerment initiatives, and creating awareness about use of maternal healthcare services among girls, women and their respective communities.

Keywords

Main Subjects


  1. Malawi National Statistical Office, ICF Macro. Malawi Demographic and Health Survey 2015-16. Zomba, Malawi, & Rockville, MD: Malawi National Statistical Office & ICF Macro; 2017.
  2. World Health Organization, UNICEF. Home visits for the newborn child: a strategy to improve survival (WHO/UNICEF joint statement). Geneva, Switzerland: WHO; 2009.
  3. UNICEF. Maternal and newborn health. New York, NY: UNICEF; 2016.
  4. World Health Organization. Maternal health. 2018. https://www.who.int/maternal-health/en/.  Accessed July 31, 2019. Published 2018.
  5. World Health Organization. Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.  Accessed July 31, 2019. Published 2018.
  6. World Health Organization. Maternal health in Nigeria: generating information for action.. https://www.who.int/maternal-health/en/.  Accessed July 31, 2019.  Published 2019.
  7. Madaj B, Smith H, Mathai M, Roos N, van den Broek N. Developing global indicators for quality of maternal and newborn care: a feasibility assessment. Bull World Health Organ. 2017;95(6):445-452i. doi:10.2471/blt.16.179531
  8. World Health Organization (WHO). Maternal and reproductive health. Geneva, Switzerland: WHO; n.d.
  9. Leslie HH, Fink G, Nsona H, Kruk ME. Obstetric facility quality and newborn mortality in Malawi: a cross-sectional study. PLoS Med. 2016;13(10):e1002151. doi:10.1371/journal.pmed.1002151
  10. Moise IK, Kalipeni E, Jusrut P, Iwelunmor JI. Assessing the reduction in infant mortality rates in Malawi over the 1990-2010 decades. Glob Public Health. 2017;12(6):757-779. doi:10.1080/17441692.2016.1239268
  11. National Statistical Office. Malawi MDG Endline Survey 2014. Zomba, Malawi: National Statistical Office; 2015.
  12. Vidler M, Ramadurg U, Charantimath U, et al. Utilization of maternal health care services and their determinants in Karnataka State, India. Reprod Health. 2016;13 Suppl 1:37. doi:10.1186/s12978-016-0138-8
  13. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria--looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9:43. doi:10.1186/1471-2393-9-43
  14. Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7:19. doi:10.1186/1471-2393-7-19
  15. Mpembeni RN, Killewo JZ, Leshabari MT, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth. 2007;7:29. doi:10.1186/1471-2393-7-29
  16. Abor PA, Abekah-Nkrumah G, Sakyi K, Adjasi CKD, Abor J. The socio-economic determinants of maternal health care utilization in Ghana. Int J Soc Econ. 2011;38(7):628-648. doi:10.1108/03068291111139258
  17. De Allegri M, Ridde V, Louis VR, et al. Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy. 2011;99(3):210-218. doi:10.1016/j.healthpol.2010.10.010
  18. Mekonnen Y, Mekonnen A. Utilization of Maternal Health Care Services in Ethiopia. Calverton, MD: ORC Macro; 2002.
  19. Muchabaiwa L, Mazambani D, Chigusiwa L, Bindu S, Mudavanhu V. Determinants of maternal healthcare utilization in Zimbabwe. Int J Econ Sci Appl Res. 2012;5(2):145-162.
  20. Anyait A, Mukanga D, Oundo GB, Nuwaha F. Predictors for health facility delivery in Busia district of Uganda: a cross sectional study. BMC Pregnancy Childbirth. 2012;12:132. doi:10.1186/1471-2393-12-132
  21. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10:31. doi:10.1186/1475-9276-10-31
  22. Burgard S. Race and pregnancy-related care in Brazil and South Africa. Soc Sci Med. 2004;59(6):1127-1146. doi:10.1016/j.socscimed.2004.01.006
  23. Katenga-Kaunda LZ. Utilisation of skilled attendance for maternal health care services in northern Malawi: rural health centres perspectives. Oslo, Norway: University of Oslo; 2010.
  24. Pell C, Menaca A, Were F, et al. Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi. PLoS One. 2013;8(1):e53747. doi:10.1371/journal.pone.0053747
  25. Agus Y, Horiuchi S. Factors influencing the use of antenatal care in rural West Sumatra, Indonesia. BMC Pregnancy Childbirth. 2012;12:9. doi:10.1186/1471-2393-12-9
  26. World Health Organization (WHO). Universal health coverage (UHC). Geneva, Switzerland: WHO; 2017.
  27. United Nations. Transforming our world: the 2030 agenda for sustainable development. New York, NY: United Nations; 2015.
  28. Tebbutt E, Brodmann R, Borg J, MacLachlan M, Khasnabis C, Horvath R. Assistive products and the sustainable development goals (SDGs). Global Health. 2016;12(1):79. doi:10.1186/s12992-016-0220-6
  29. Griggs DJ, Nilsson M, Stevance A, McCollum D. A guide to SDG interactions: from science to implementation. Paris, France: International Council for Science; 2017.
  30. Howden-Chapman P, Siri J, Chisholm E, Chapman R, Doll CNH, Capon A. SDG 3: Ensure healthy lives and promote wellbeing for all at all ages. In: Griggs DJ, Nilsson M, Stevance A, McCollum D, eds. A guide to SDG interactions: from science to implementation. Paris, France: International Council for Science; 2017:81-126.
  31. Veneman AM. Education is key to reducing child mortality: the link between maternal health and education. UN Chronicle. 2007;XLIV(4). https://unchronicle.un.org/article/education-key-reducing-child-mortality-link-between-maternal-health-and-education.
  32. Nilsson M, Griggs D, Visbeck M. Policy: map the interactions between Sustainable Development Goals. Nature. 2016;534(7607):320-322. doi:10.1038/534320a
  33. UNESCO. Girls' education - the facts: Education for All Global Monitoring Report. Paris, France: UNESCO; 2013.
  34. Swartling Peterson S, Wedenig J. Improving care for mothers and babies in Malawi. New York, NY: UNICEF; 2017.
  35. United States Agency for International Development (USAID). Malawi maternal, neonatal and child health fact sheet. Washington, DC: USAID; 2016.
  36. Colbourn T, Lewycka S, Nambiar B, Anwar I, Phoya A, Mhango C. Maternal mortality in Malawi, 1977-2012. BMJ Open. 2013;3(12):e004150. doi:10.1136/bmjopen-2013-004150
  37. World Health Organization (Regional Office for Africa). Maternal health; Why do women not get the care they need? Geneva, Switzerland: WHO; n.d.
  38. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. Psychosoc Med. 2012;9:Doc11. doi:10.3205/psm000089
  39. Gochman DS. Handbook of health behaviour research: personal and social determinants. New York, NY: Plenum; 1997.
  40. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51(1):95-124.
  41. Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285(2):200-206. doi:10.1001/jama.285.2.200
  42. White L, McQuillan J, Greil AL, Johnson DR. Infertility: testing a helpseeking model. Soc Sci Med. 2006;62(4):1031-1041. doi:10.1016/j.socscimed.2005.11.012
  43. Gruber S, Kiesel M. Inequality in health care utilization in Germany? Theoretical and empirical evidence for specialist consultation. J Public Health. 2010;18(4):351-365. doi:10.1007/s10389-010-0321-2
  44. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208-220.
  45. Malawi National Statistical Office, ICF Macro. Malawi Demographic and Health Survey 2010. Zomba, Malawi: Malawi National Statistical Office & ICF Macro; 2011.
  46. The DHS Program. Wealth index. Rockville, MD: ICF; n.d.
  47. Rutstein SO. Steps to constructing the new DHS Wealth Index. Rockville, MD: ICF; n.d.
  48. World Bank (Lilongwe Water and Sanitation Project). Project information document/Integrated safeguards data sheet (PID/ISDS). Washington, DC: World Bank; 2017.
  49. Adebowale SA, Udjo E. Maternal health care services access index and infant survival in Nigeria. Ethiop J Health Sci. 2016;26(2):131-144. doi:10.4314/ejhs.v26i2.7
  50. Pallant J. SPSS survival manual: a step by step guide to data analysis using IBM SPSS. 5th ed. Berkshire, England: McGraw Hill; 2013.
  51. Kongnyuy EJ, Hofman J, Mlava G, Mhango C, van den Broek N. Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi. Matern Child Health J. 2009;13(5):687-694. doi:10.1007/s10995-008-0380-y
  52. Malawi National Statistical Office, UNICEF. Malawi multiple indicator cluster survey 2006. Zomba, Malawi: Malawi National Statistical Office & UNICEF; 2008.
  53. World Health Organization (WHO). Standards for maternal and neonatal care. Geneva, Switzerland: WHO; 2007.
  54. Government of Malawi Ministry of Health. Health sector strategic plan II (2017-2022). Lilongwe, Malawi: Government of Malawi Ministry of Health; 2017.
  55. Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries: DHS comparative reports 26. Calverton, MD: ICF Macro; 2011.
  56. Pfeiffer C, Mwaipopo R. Delivering at home or in a health facility? health-seeking behaviour of women and the role of traditional birth attendants in Tanzania. BMC Pregnancy Childbirth. 2013;13:55. doi:10.1186/1471-2393-13-55
  57. Khanal V, Adhikari M, Karkee R, Gavidia T. Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal demographic and health survey 2011. BMC Womens Health. 2014;14:19. doi:10.1186/1472-6874-14-19
  58. Warren C, Daly P, Toure L, Mongi P. Postnatal care. In: Lawn J, Kerber K, eds. Opportunities for Africa's newborns: practical data, policy and programmatic support for newborn care in Africa. Geneva, Swizterland: Partnership for Maternal, Newborn and Child Health; 2006:79-90.
  59. Yaya S, Bishwajit G, Shah V. Wealth, education and urban-rural inequality and maternal healthcare service usage in Malawi. BMJ Glob Health. 2016;1(2):e000085. doi:10.1136/bmjgh-2016-000085
  60. Baral YR, Lyons K, Skinner J, van Teijlingen ER. Maternal health services utilisation in Nepal: Progress in the new millennium? Health Sci J. 2012;6(4):618-633.
  61. Chakraborty N, Islam MA, Chowdhury RI, Bari W, Akhter HH. Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int. 2003;18(4):327-337. doi:10.1093/heapro/dag414
  62. Lungu EA, Biesma R, Chirwa M, Darker C. Healthcare seeking practices and barriers to accessing under-five child health services in urban slums in Malawi: a qualitative study. BMC Health Serv Res. 2016;16(1):410. doi:10.1186/s12913-016-1678-x
  63. Wedenig J, Nyarko E. Malawi aims to improve quality of care for mothers and new babies. Geneva, Switzerland: Partnership for Maternal, Newborn and Child Health; 2017.
  64. Singh K, Story WT, Moran AC. Assessing the continuum of care pathway for maternal health in South Asia and sub-Saharan Africa. Matern Child Health J. 2016;20(2):281-289. doi:10.1007/s10995-015-1827-6
  65. UNESCO. Education for people and planet: creating sustainable futures for all, Global education monitoring report. Paris, France: UNESCO; 2016.
  66. Tsala Dimbuene Z, Amo-Adjei J, Amugsi D, Mumah J, Izugbara CO, Beguy D. Women's education and utilization of maternal health services in Africa: A multi-country and socioeconomic status analysis. J Biosoc Sci. 2018;50(6):725-748. doi:10.1017/s0021932017000505
  67. Chimatiro CS, Hajison P, Chipeta E, Muula AS. Understanding barriers preventing pregnant women from starting antenatal clinic in the first trimester of pregnancy in Ntcheu District-Malawi. Reprod Health. 2018;15(1):158. doi:10.1186/s12978-018-0605-5
  68. Abel Ntambue ML, Francoise Malonga K, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo--a case study of Lubumbashi City. BMC Pregnancy Childbirth. 2012;12:66. doi:10.1186/1471-2393-12-66
  69. Banda CL. Barriers to utilization of focused antenatal care among pregnant women in Ntchisi district in Malawi. Tampere, Finland: University of Tampere; 2013.
  70. Mrisho M, Obrist B, Schellenberg JA, et al. The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy Childbirth. 2009;9:10. doi:10.1186/1471-2393-9-10
  71. Lincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. Antenatal care. In: Lawn J, Kerber K, eds. Opportunities for Africa’s newborns: Practical data, policy and programmatic support for newborn care in Africa. Geneva, Switzerland: Partnership for Maternal, Newborn and Child Health; 2006:51-62.
  72. Machira K, Palamuleni M. Women's perspectives on quality of maternal health care services in Malawi. Int J Womens Health. 2018;10:25-34. doi:10.2147/ijwh.s144426
  73. United Nations. The Millennium Development Goals Report 2015. New York, NY: United Nations; 2015.
  74. Vallières F, Hansen A, McAuliffe E, et al. Head of household education level as a factor influencing whether delivery takes place in the presence of a skilled birth attendant in Busia, Uganda: a cross-sectional household study. BMC Pregnancy Childbirth. 2013;13:48. doi:10.1186/1471-2393-13-48
  75. Zamawe CF, Masache GC, Dube AN. The role of the parents' perception of the postpartum period and knowledge of maternal mortality in uptake of postnatal care: a qualitative exploration in Malawi. Int J Womens Health. 2015;7:587-594. doi:10.2147/ijwh.s83228
  76. Sedgwick P. Ecological studies: advantages and disadvantages. BMJ. 2014;348:g2979. doi:10.1136/bmj.g2979
  77. Porta M. A dictionary of epidemiology. 6th ed. Oxford UK: Oxford University Press; 2014.
  78. Porter EJ. Research on home care utilization: A critical analysis of the preeminent approach. J Aging Stud. 2000;14(1):25-38. doi:10.1016/S0890-4065(00)80014-6
  79. Aday LA, Awe WC. Health services utilization models. In: Gochman DS, ed. Handbook of health behaviour research: personal and social determinants. New York, NY: Plenum; 1997:153-172.
  80. Rosenau PV. Reflections on the cost consequences of the new gene technology for health policy. Int J Technol Assess Health Care. 1994;10(4):546-561.
  81. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
  82. de Bernis L, Sherratt DR, AbouZahr C, Van Lerberghe W. Skilled attendants for pregnancy, childbirth and postnatal care. Br Med Bull. 2003;67:39-57. doi:10.1093/bmb/ldg017
Volume 8, Issue 12
December 2019
Pages 700-710
  • Receive Date: 13 September 2018
  • Revise Date: 31 July 2019
  • Accept Date: 03 August 2019
  • First Publish Date: 01 December 2019