Mapping the prevalence and sociodemographic characteristics of women who deliver alone: Evidence from demographic and health surveys from 80 countries

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Study Justification:
– Quality skilled care during labor and delivery is crucial for improving maternal and newborn health outcomes.
– Analysis of Demographic and Health Survey (DHS) data reveals a significant number of women worldwide who not only lack access to skilled care but also deliver alone with no one present (NOP).
– This study aims to map the prevalence and sociodemographic characteristics of women who deliver alone in 80 countries to highlight the extent of the issue and identify areas for intervention.
Study Highlights:
– The practice of delivering with NOP is concentrated in West and Central Africa and parts of East Africa.
– Women who are poor, older, of higher parity, living in rural areas, and uneducated are more likely to give birth with NOP.
– Increased use of antenatal care services is associated with a decline in the proportion of women giving birth with NOP.
– Nigeria alone accounts for 44% of deliveries with NOP, with an estimated 2.2 million women delivering alone between 2005 and 2015.
Recommendations for Lay Reader and Policy Maker:
– Countries should prioritize reducing inequalities in access to healthcare, wealth, education, and family planning.
– Concurrent efforts to change community norms that condone and facilitate the practice of women giving birth alone must be implemented.
– Programmatic experience from Sokoto State in northern Nigeria suggests that grassroots community advocacy and education can significantly reduce the practice, even in poor and low-resource areas.
– Urgent action is needed to eradicate the practice of giving birth alone to prevent preventable maternal and newborn deaths.
Key Role Players:
– Government health departments and ministries
– Non-governmental organizations (NGOs) working in maternal and newborn health
– Community leaders and advocates
– Healthcare providers and professionals
– Researchers and academics
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers
– Community advocacy and education programs
– Development and implementation of policies and guidelines
– Monitoring and evaluation systems
– Data collection and analysis
– Communication and awareness campaigns
– Infrastructure and equipment improvements in healthcare facilities
– Support for antenatal care services
– Support for family planning services
– Research and innovation in maternal and newborn health

Evidence has shown that quality skilled care during labor and delivery is essential to improve maternal and newborn health outcomes. Unfortunately, analyses of Demographic and Health Survey (DHS) data show that there are a substantial number of women around the world that not only do not have access to skilled care but also deliver alone with no one present (NOP). Among the 80 countries with data, we found the practice of delivering with NOP was concentrated in West and Central Africa and parts of East Africa. Across these countries, the prevalence of giving birth with NOP was higher among women who were poor, older, of higher parity, living in rural areas, and uneducated than among their counterparts. As women increased use of antenatal care services, the proportion giving birth with NOP declined. Using census data for each country from the US Census Bureau’s International Database and data on prevalence of delivering with NOP from the DHS among countries with surveys from 2005 onwards (n=59), we estimated the number of women who gave birth alone in each country, as well as each country’s contribution to the total burden. Our analysis indicates that between 2005 and 2015, an estimated 2.2 million women, who had given birth in the 3 years preceding each country survey, delivered with NOP. Nigeria, alone, accounted for 44% (nearly 1 million) of these deliveries. As countries work on reducing inequalities in access to health care, wealth, education, and family planning, concurrent efforts to change community norms that condone and facilitate the practice of women giving birth alone must also be implemented. Programmatic experience from Sokoto State in northern Nigeria suggests that the practice can be reduced markedly through grassroots community advocacy and education, even in poor and low-resource areas. It is time for leaders to act now to eradicate the practice of giving birth alone-one of many important steps needed to ensure no mother or newborn dies of a preventable death.

Since 1984, the Demographic and Health Surveys (DHS) have been conducted in at least 85 countries.9 DHS data have documented the association between skilled assistance at delivery and lower rates of mortality and morbidity among mothers and their newborns.10,11 In addition to quantifying the prevalence of skilled birth attendance, the DHS also explicitly collects data on women who gave birth with NOP. For our analysis, we used publicly available data from the DHS program’s STATcompiler database to profile the distribution of delivery with NOP across countries, as well as to identify which sub-populations within countries were most likely to engage in this risky practice.12 Data on women giving birth alone were available for 80 countries. The STATcompiler database also enabled us to stratify all live births that occurred with NOP in the 3 years preceding the most recent country DHS survey on several indicators. The variables available were urban/rural residence, wealth quintile, mother’s age, number of antenatal care (ANC) visits, birth order, and mother’s level of education. Although most countries had full data on these stratification variables, some disaggregated data were missing for Botswana, Ecuador, El Salvador, Mexico, Sri Lanka, Sudan, Thailand, and Trinidad and Tobago. We also sought to estimate each country’s contribution to the total burden of women who gave birth alone among surveyed countries. In doing this, we used the mid-year population of women between the ages of 15–49, as calculated by the US Census Bureau’s International Database, during the same year as each DHS, adjusted for the general fertility rates (as presented in STATcompiler) for the 3 years preceding each survey year. For these analyses, we found census data for the same year as the DHS data for 77 countries. (Census data were missing for Ecuador, Sudan, and Thailand and were excluded from the analysis because they did not have recent DHS surveys conducted after 2004; see below.)13 These numbers were used to calculate a rough estimate of the number of women who would have given birth alone, given the prevalence rates of delivery with NOP at the time of the most recent DHS survey after 2004. We excluded 18 countries in the final analyses (besides Ecuador, Sudan, and Thailand mentioned above) as they had no data available after 2004. These countries were Botswana, Brazil, Central African Republic, Chad, Eritrea, Guatemala, Mauritania, Mexico, Morocco, Nicaragua, Paraguay, South Africa, Sri Lanka, Trinidad and Tobago, Turkey, Turkmenistan, Uzbekistan, and Vietnam. This yielded a total of 59 countries with recent data that were used to assess the number of women giving birth alone. Data from the DHS and the US Census Bureau are both open access and publicly available. Additionally, as standard protocol, each DHS survey received in-country ethical clearance. As both of these data sources are anonymized, we did not seek any additional ethical approval for this work.

Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health:

1. Community Advocacy and Education: Implement grassroots community advocacy and education programs, similar to the programmatic experience in Sokoto State, Nigeria, to reduce the practice of women giving birth alone. These programs can help change community norms and raise awareness about the importance of skilled care during labor and delivery.

2. Strengthening Antenatal Care Services: Increase the utilization of antenatal care services, as the analysis showed that as women increased their use of these services, the proportion of women giving birth alone declined. This can be achieved through targeted interventions such as improving access to antenatal care clinics, providing education on the benefits of antenatal care, and addressing barriers that prevent women from accessing these services.

3. Addressing Inequalities: Work on reducing inequalities in access to healthcare, wealth, education, and family planning. By addressing these underlying factors, it can help improve access to skilled care during labor and delivery and reduce the prevalence of women giving birth alone.

4. Data Collection and Analysis: Continue conducting Demographic and Health Surveys (DHS) to collect data on the prevalence of skilled birth attendance and women giving birth alone. This data can help identify trends, target interventions, and monitor progress over time.

5. Collaboration and Partnerships: Foster collaboration and partnerships between governments, non-governmental organizations, healthcare providers, and community leaders to collectively work towards eradicating the practice of women giving birth alone. This can involve sharing best practices, resources, and expertise to implement effective interventions.

It is important to note that these recommendations are based on the information provided and may need to be tailored to specific contexts and resources available in each country.
AI Innovations Description
The recommendation to improve access to maternal health based on the provided information is to implement grassroots community advocacy and education programs. This approach has shown promising results in reducing the practice of women giving birth alone, even in poor and low-resource areas like Sokoto State in northern Nigeria.

Leaders and policymakers should prioritize efforts to change community norms that condone and facilitate the practice of delivering with no one present. This can be achieved through community-based programs that raise awareness about the importance of skilled care during labor and delivery, and the potential risks associated with delivering alone. These programs should also provide education on the benefits of antenatal care services and promote their utilization.

In addition to addressing access to healthcare, efforts should focus on reducing inequalities in wealth, education, and family planning. By addressing these underlying factors, the prevalence of delivering with no one present can be further reduced.

It is crucial for leaders to take immediate action to eradicate the practice of giving birth alone, as it is one of many important steps needed to ensure that no mother or newborn dies of a preventable death.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and trained healthcare professionals in areas with limited access to maternal health services can help improve access and quality of care.

2. Community-based interventions: Implementing community-based programs that educate and empower women and their families about the importance of skilled care during labor and delivery can help increase awareness and utilization of maternal health services.

3. Mobile health (mHealth) solutions: Utilizing mobile technology to provide information, reminders, and access to healthcare services can help overcome barriers to accessing maternal health services, especially in remote areas.

4. Financial incentives: Providing financial incentives, such as cash transfers or health insurance coverage, to pregnant women and their families can help reduce financial barriers and increase utilization of maternal health services.

5. Transportation support: Addressing transportation challenges by providing affordable and accessible transportation options for pregnant women can help ensure timely access to maternal health services, particularly in rural areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the proportion of women receiving skilled care during labor and delivery, the number of women delivering alone, or the distance to the nearest healthcare facility.

2. Collect baseline data: Gather data on the current status of the indicators in the target population or region. This can be done through surveys, interviews, or existing data sources like the Demographic and Health Surveys (DHS).

3. Define the intervention scenarios: Develop different scenarios that represent the potential impact of the recommendations. For example, one scenario could assume the implementation of community-based interventions, while another scenario could consider the impact of strengthening healthcare infrastructure.

4. Model the impact: Use statistical or mathematical models to estimate the potential impact of each scenario on the selected indicators. This can involve analyzing the data collected in step 2 and applying appropriate statistical techniques or simulation models.

5. Evaluate the results: Compare the outcomes of each scenario to the baseline data to assess the potential improvement in access to maternal health. This evaluation can help identify the most effective recommendations and prioritize interventions for implementation.

6. Refine and iterate: Based on the evaluation results, refine the recommendations and iterate the simulation process to further optimize the impact on improving access to maternal health.

It’s important to note that the specific methodology and data requirements may vary depending on the context and available resources. Consulting with experts in the field of maternal health and utilizing existing research and data sources can help ensure the accuracy and validity of the simulation results.

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