Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo – A Case study of Lubumbashi City

BMC Pregnancy and Childbirth, Volume 12, Year 2012

Interpretation

Background: The use of maternal health services, known as an indirect indicator of perinatal death, is still unknown in Lubumbashi. The present study was therefore undertaken in order to determine the factors that influence the use of mother and child healthcare services in Lubumbashi, Democratic Republic of the Congo.Methods: This was transversal study of women residing in Lubumbashi who had delivered between January and December 2009. In total, 1762 women were sampled from households using indicator cluster surveys in all health zones. Antenatal consultations (ANC), delivery assisted by qualified healthcare personnel (and delivery in a healthcare facility) as well as postnatal consultations (PNC) were dependent variables of study. The factors determining non-use of maternal healthcare services were researched via logistic regression with a 5% materiality threshold.Results: The use of maternal healthcare services was variable; 92.6% of women had attended ANC at least once, 93.8% of women had delivered at a healthcare facility, 97.2% had delivered in the presence of qualified healthcare personnel, while the rate of caesarean section was 4.5%. Only 34.6% postnatal women had attended PNC by 42 days after delivery. During these ANC visits, only 60.6% received at least one dose of vaccine, while 38.1% received Mebendazole, 35.6% iron, 32.7% at least one dose of SulfadoxinePyrimethamine, 29.2% folic acid, 15.5% screening for HIV and 12.8% an insecticide treated net.In comparison to women that had had two or three deliveries before, primiparous and grand multiparous women were twice as likely not to use ANC during their pregnancy. Women who had unplanned pregnancies were also more likely not to use ANC or PNC than those who had planned pregnancies alone or with their partner. The women who had not used ANC were also more likely not to use PNC. The women who had had a trouble-free delivery were more likely not to use PNC than those who had complications when delivering.Conclusion: In Lubumbashi, a significant proportion of women continue not to make use of healthcare services during pregnancy, as well as during and after childbirth. Women giving birth for the first time, those who have already given birth many times, and women with an unwanted pregnancy, made less use of ANC. Moreover, women who had not gone for ANC rarely came back for postnatal consultations, even if they had given birth at a healthcare facility. Similarly, those who gave birth without complications, less frequently made use of postnatal consultations. As with ANCs, women with unwanted pregnancies rarely went for postnatal visits.In addition to measures aimed at reinforcing women’s autonomy, efforts are also needed to reinforce and improve the information given to women of childbearing age, as well as communication between the healthcare system and the community, and participation from the community, since this will contribute to raising awareness of safe motherhood and the use of such services, including family planning. © 2012 Ntambue et al.; licensee BioMed Central Ltd. The study was carried out in the city of Lubumbashi, the Democratic Republic of Congo. Lubumbashi is the administrative centre of Katanga province and the second most populated city in DRC after Kinshasa. It is located in the South East of the DRC, 135 km from the northern boarder of Zambia. Although no census has taken place here since 1984, fore casts within the vaccination programme of 2009 estimated this population to be 1,415,835[7], and the rate of natural growth is as for the whole country at 4% [8]. The city consists of seven administrative districts and eleven healthcare zones; some of which are urban–rural. In order of magnitude, the population is spread as follows in the healthcare zones: Kampemba (276,112), Katuba (200,829), Ruashi (194,355), Lubumbashi (127,071), Kenya (116,766), Kisanga (116,297), Tshiamilemba (111,074), Mumbunda (108,365), Vangu (91,986), Kamalondo (49,393), Kowe (23,587) [7]. Data were collected in specific areas in each of these healthcare zones. This was a transversal study carried out in order to determine the use of maternal healthcare services in Lubumbashi. Data were collected between January and February 2010 with help of a questionnaire written in French (interpreted in accordance with the understanding of the interviewee) consisting of closed and semi-open questions administered by surveyors. A pre-survey was carried out in order to test the questionnaire. The study was carried out on women residing in Lubumbashi who had delivered during the 12 months prior to the survey (January to December 2009). Women who delivered in Lubumbashi during the same period but had not lived there during their pregnancy were excluded from our sample [9]. Women’s informed consent was obtained prior to commencing the interview. This study was conducted in collaboration with the provincial office of the national program of the reproductive health (PNSR), and it was approved and authorized by the medical ethics committee of the University of Lubumbashi. Sample size was calculated according to antenatal consultation coverage of 78% in the province of Katanga [5]. With an accuracy of 3% and a confidence level of 95%, a proportion of non-respondents of 10% and a design effect of two, at least 1460 women were recruited for our study [9]. Women were selected by cluster sampling. The clusters were made up of the different healthcare areas. There were 30 clusters for the whole city (Table (Table1)1) and clusters were selected by systematic random sampling according to the cumulative frequency of the population that used these services during 2009 [9]. Number of clusters and subjects surveyed according to healthcare zones In the same cluster, data collection was carried out systematically according to households using a set inclusion criteria until the limit number required for the healthcare area was reached [9]. Women’s and household data were collected including socio-demographic, attendance at ANC (reasons for attendance and non-attendance, the health interventions received, perceptions of the quality of care received), the place of delivery and the presence of qualified healthcare personnel at the time of delivery, as well as the use of PNC. Women were interviewed within the households. In order to verify the exactness of the information provided by the women, each one was asked to give the name of the facility where she went for antenatal consultations (ANC). At the facility, the data of the interviewed women were looked up in the registers and records of ANC, and compared with the women’s statements. This procedure was followed as women in Lubumbashi do not have ANC cards on which the frequency and care administered during ANC can be indicated. All such information is usually written in the register and record, which is often kept at the ANC facility. In rare cases where women take the ANC sheet with them, they either tend to forget it at home at the time of childbirth, or they leave it at the maternity home after the birth. Information regarding the delivery itself was obtained by going to the maternity home. Besides the information provided by each woman, the healthcare facility in which she gave birth was visited to confirm the status of the healthcare staff who attended the birth. At the same time, information regarding complications and the outcome of the delivery was obtained. For women who gave birth at home, the name of the healthcare practitioner who attended the birth was searched in order to confirm their training and aptitude to attend during childbirth. This information was obtained by interviewing the person in question. The status of personnel qualified to attend childbirth was recognised if, in addition to their basic training as healthcare practitioner, they had attended at least one birth in the month preceding the delivery in relation to which the information is sought. If the person could not be found, the healthcare area or the official nurse of the healthcare centre was contacted to confirm the status of the person who attended the birth. In total, 2177 of the households visited had at least one woman who had carried a pregnancy in 2009. Among these, 0.9% (20 women) had miscarried, 0.2% (four) had died during pregnancy, 17.5% (381) were still pregnant at the time of the survey and 81.3% (1772) had already delivered. Among the women who had delivered, 0.2% (three) had died during delivery, 0.2% (four) had died within the 42 days after delivery and 0.2% (three) of the survivors refused to take part in the survey. All together, 1762 women who had delivered during 2009 took part in the survey. Included in maternal healthcare services were antenatal consultations, delivery assisted by qualified healthcare personnel and postnatal consultations. The use of healthcare services was defined as being the use and access to healthcare linked to these services at a health facility. ANC was defined as healthcare linked to pregnancy received by a woman at a health facility before labour [4]. Assisted delivery was defined as delivery taking place under supervision of qualified healthcare personnel. Qualified healthcare personnel was considered as all healthcare professionals who have accredited training in healthcare and have the competencies required to enable them to oversee pregnancy, delivery and immediate normal postpartum period, as well as knowing how to identify, treat, and when necessary, take the decision to transfer women or newborn presenting with complications. This category was comprised of doctors and nurses, while traditional midwives were not included [10]. With regard to postnatal consultations, these are planned according to the rule of six: six hours, six days and six weeks after delivery [4]. At least one visit at the facility is expected within a maximum period of 42 days following delivery and at least two visits are expected after this period. Within the framework of this research, we evaluated recourse to the PNC for respective periods of seven days, 28 days (corresponding to the end of the neonatal period) and 42 days [4,11]. Use of healthcare services was defined as use of and access to healthcare linked to these services at a health facility, whereas non-use was defined as the absence of use and the lack of access to healthcare linked to these services. Non-use of ANC, PNC and home delivery were studied as dependent variables. Thus, the women who had not attended ANC were considered as not having used this service; they were compared to those who had attended them at least once during pregnancy. In addition, the women who had delivered at home were compared to those who had delivered at a health facility. All of the women who had not used PNC within seven days, 28 days and 42 days (limit days inclusive) after delivery were compared with those who had used them respectively during the course of these periods. The different data collected were processed and analysed using Stata 11.0 software. The use of each of the healthcare services was calculated as the proportion of women having used the service in comparison with the total women surveyed. The different quantitative variables (age, gestational age at first visit, frequency of visits, age of the child at the first postnatal visit) were synthesized for their position and dispersion parameters. The comparison of quantitative variables was performed using Student’s t-test or the Mann–Whitney test accordingly [12]. The qualitative variables were compared using the chi-square test. The materiality threshold was 5%. Odds ratios (OR) and their 95% confidence intervals (95%CI) were calculated in order to estimate the strength of association between dependent variables and independent variables. Logistic regression models were established by progressive selection and only statistically significant variables were conserved. In the tables, the OR (95%CI) derived from final logistic models were presented as well as the p-value of the Wald test. The suitability of the models was verified using the Hosmer and Lemeshow test [12,13]. The materiality threshold was set at 5% for all analyses, which were performed using Stata 11.0 software.

AI Digest

Study Justification:

– The study aimed to determine the factors that influence the use of maternal and child healthcare services in Lubumbashi, Democratic Republic of the Congo.
– The use of maternal healthcare services is an indirect indicator of perinatal death, and understanding the factors that affect utilization can help improve maternal and child health outcomes.
– The study was conducted in an urban setting, which is important as urban areas often have different healthcare challenges compared to rural areas.

Study Highlights:

– The study found that the use of maternal healthcare services in Lubumbashi was variable. While a high percentage of women attended antenatal consultations and delivered at a healthcare facility, the rate of postnatal consultations was low.
– Primiparous and grand multiparous women, as well as women with unplanned pregnancies, were less likely to use antenatal and postnatal care services.
– Women who had not used antenatal care were also less likely to use postnatal care services.
– Women who had trouble-free deliveries were less likely to use postnatal care services compared to those who had complications during delivery.

Recommendations for Lay Reader and Policy Maker:

– Efforts should be made to reinforce women’s autonomy and improve the information given to women of childbearing age.
– Communication between the healthcare system and the community should be improved, and community participation should be encouraged to raise awareness of safe motherhood and the use of healthcare services, including family planning.

Key Role Players:

– Healthcare professionals, including doctors and nurses, who have the competencies required to oversee pregnancy, delivery, and postpartum care.
– Community leaders and organizations that can help disseminate information and raise awareness about maternal and child healthcare services.
– Government agencies and policymakers responsible for implementing and funding healthcare programs.

Cost Items for Planning Recommendations:

– Training programs for healthcare professionals to improve their skills and knowledge in maternal and child healthcare.
– Information and education campaigns targeting women of childbearing age to raise awareness about the importance of maternal and child healthcare services.
– Communication materials, such as brochures and posters, to disseminate information about healthcare services.
– Community engagement activities, such as workshops and community meetings, to promote participation and awareness.
– Monitoring and evaluation systems to track the implementation and impact of the recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong because it provides specific data on the use of maternal healthcare services in Lubumbashi, Democratic Republic of Congo. The study includes a large sample size of 1762 women and uses logistic regression analysis to determine the factors influencing the use of these services. However, to improve the evidence, the abstract could provide more information on the methodology used, such as the sampling technique and data collection process. Additionally, it would be helpful to include the key findings and implications of the study.

Abstract

The study was carried out in the city of Lubumbashi, the Democratic Republic of Congo. Lubumbashi is the administrative centre of Katanga province and the second most populated city in DRC after Kinshasa. It is located in the South East of the DRC, 135 km from the northern boarder of Zambia. Although no census has taken place here since 1984, fore casts within the vaccination programme of 2009 estimated this population to be 1,415,835[7], and the rate of natural growth is as for the whole country at 4% [8]. The city consists of seven administrative districts and eleven healthcare zones; some of which are urban–rural. In order of magnitude, the population is spread as follows in the healthcare zones: Kampemba (276,112), Katuba (200,829), Ruashi (194,355), Lubumbashi (127,071), Kenya (116,766), Kisanga (116,297), Tshiamilemba (111,074), Mumbunda (108,365), Vangu (91,986), Kamalondo (49,393), Kowe (23,587) [7]. Data were collected in specific areas in each of these healthcare zones. This was a transversal study carried out in order to determine the use of maternal healthcare services in Lubumbashi. Data were collected between January and February 2010 with help of a questionnaire written in French (interpreted in accordance with the understanding of the interviewee) consisting of closed and semi-open questions administered by surveyors. A pre-survey was carried out in order to test the questionnaire. The study was carried out on women residing in Lubumbashi who had delivered during the 12 months prior to the survey (January to December 2009). Women who delivered in Lubumbashi during the same period but had not lived there during their pregnancy were excluded from our sample [9]. Women’s informed consent was obtained prior to commencing the interview. This study was conducted in collaboration with the provincial office of the national program of the reproductive health (PNSR), and it was approved and authorized by the medical ethics committee of the University of Lubumbashi. Sample size was calculated according to antenatal consultation coverage of 78% in the province of Katanga [5]. With an accuracy of 3% and a confidence level of 95%, a proportion of non-respondents of 10% and a design effect of two, at least 1460 women were recruited for our study [9]. Women were selected by cluster sampling. The clusters were made up of the different healthcare areas. There were 30 clusters for the whole city (Table (Table1)1) and clusters were selected by systematic random sampling according to the cumulative frequency of the population that used these services during 2009 [9]. Number of clusters and subjects surveyed according to healthcare zones In the same cluster, data collection was carried out systematically according to households using a set inclusion criteria until the limit number required for the healthcare area was reached [9]. Women’s and household data were collected including socio-demographic, attendance at ANC (reasons for attendance and non-attendance, the health interventions received, perceptions of the quality of care received), the place of delivery and the presence of qualified healthcare personnel at the time of delivery, as well as the use of PNC. Women were interviewed within the households. In order to verify the exactness of the information provided by the women, each one was asked to give the name of the facility where she went for antenatal consultations (ANC). At the facility, the data of the interviewed women were looked up in the registers and records of ANC, and compared with the women’s statements. This procedure was followed as women in Lubumbashi do not have ANC cards on which the frequency and care administered during ANC can be indicated. All such information is usually written in the register and record, which is often kept at the ANC facility. In rare cases where women take the ANC sheet with them, they either tend to forget it at home at the time of childbirth, or they leave it at the maternity home after the birth. Information regarding the delivery itself was obtained by going to the maternity home. Besides the information provided by each woman, the healthcare facility in which she gave birth was visited to confirm the status of the healthcare staff who attended the birth. At the same time, information regarding complications and the outcome of the delivery was obtained. For women who gave birth at home, the name of the healthcare practitioner who attended the birth was searched in order to confirm their training and aptitude to attend during childbirth. This information was obtained by interviewing the person in question. The status of personnel qualified to attend childbirth was recognised if, in addition to their basic training as healthcare practitioner, they had attended at least one birth in the month preceding the delivery in relation to which the information is sought. If the person could not be found, the healthcare area or the official nurse of the healthcare centre was contacted to confirm the status of the person who attended the birth. In total, 2177 of the households visited had at least one woman who had carried a pregnancy in 2009. Among these, 0.9% (20 women) had miscarried, 0.2% (four) had died during pregnancy, 17.5% (381) were still pregnant at the time of the survey and 81.3% (1772) had already delivered. Among the women who had delivered, 0.2% (three) had died during delivery, 0.2% (four) had died within the 42 days after delivery and 0.2% (three) of the survivors refused to take part in the survey. All together, 1762 women who had delivered during 2009 took part in the survey. Included in maternal healthcare services were antenatal consultations, delivery assisted by qualified healthcare personnel and postnatal consultations. The use of healthcare services was defined as being the use and access to healthcare linked to these services at a health facility. ANC was defined as healthcare linked to pregnancy received by a woman at a health facility before labour [4]. Assisted delivery was defined as delivery taking place under supervision of qualified healthcare personnel. Qualified healthcare personnel was considered as all healthcare professionals who have accredited training in healthcare and have the competencies required to enable them to oversee pregnancy, delivery and immediate normal postpartum period, as well as knowing how to identify, treat, and when necessary, take the decision to transfer women or newborn presenting with complications. This category was comprised of doctors and nurses, while traditional midwives were not included [10]. With regard to postnatal consultations, these are planned according to the rule of six: six hours, six days and six weeks after delivery [4]. At least one visit at the facility is expected within a maximum period of 42 days following delivery and at least two visits are expected after this period. Within the framework of this research, we evaluated recourse to the PNC for respective periods of seven days, 28 days (corresponding to the end of the neonatal period) and 42 days [4,11]. Use of healthcare services was defined as use of and access to healthcare linked to these services at a health facility, whereas non-use was defined as the absence of use and the lack of access to healthcare linked to these services. Non-use of ANC, PNC and home delivery were studied as dependent variables. Thus, the women who had not attended ANC were considered as not having used this service; they were compared to those who had attended them at least once during pregnancy. In addition, the women who had delivered at home were compared to those who had delivered at a health facility. All of the women who had not used PNC within seven days, 28 days and 42 days (limit days inclusive) after delivery were compared with those who had used them respectively during the course of these periods. The different data collected were processed and analysed using Stata 11.0 software. The use of each of the healthcare services was calculated as the proportion of women having used the service in comparison with the total women surveyed. The different quantitative variables (age, gestational age at first visit, frequency of visits, age of the child at the first postnatal visit) were synthesized for their position and dispersion parameters. The comparison of quantitative variables was performed using Student’s t-test or the Mann–Whitney test accordingly [12]. The qualitative variables were compared using the chi-square test. The materiality threshold was 5%. Odds ratios (OR) and their 95% confidence intervals (95%CI) were calculated in order to estimate the strength of association between dependent variables and independent variables. Logistic regression models were established by progressive selection and only statistically significant variables were conserved. In the tables, the OR (95%CI) derived from final logistic models were presented as well as the p-value of the Wald test. The suitability of the models was verified using the Hosmer and Lemeshow test [12,13]. The materiality threshold was set at 5% for all analyses, which were performed using Stata 11.0 software.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health in Lubumbashi, Democratic Republic of Congo:

1. Mobile clinics: Implementing mobile clinics that travel to different areas of Lubumbashi, especially in rural or underserved areas, to provide maternal health services. This would increase accessibility for women who may have difficulty traveling to healthcare facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This would be particularly beneficial for women who live far from healthcare facilities or have limited mobility.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support in local communities. These workers can help bridge the gap between healthcare facilities and the community, improving access to care.

4. Awareness campaigns: Conducting targeted awareness campaigns to educate women and their families about the importance of maternal health services and the available resources in Lubumbashi. This can help address misconceptions and cultural barriers that may prevent women from seeking care.

5. Financial incentives: Implementing financial incentives, such as cash transfers or subsidies, to encourage women to seek and utilize maternal health services. This can help alleviate financial barriers that may prevent women from accessing care.

6. Strengthening healthcare infrastructure: Investing in improving healthcare infrastructure, including facilities, equipment, and staffing, to ensure that quality maternal health services are available and accessible to all women in Lubumbashi.

7. Integration of services: Integrating maternal health services with other healthcare services, such as family planning and HIV testing, to provide comprehensive care to women. This can improve efficiency and convenience for women seeking multiple services.

It is important to note that these recommendations are based on the information provided and may need to be further tailored to the specific context and needs of Lubumbashi.

AI Innovations Description

The study conducted in Lubumbashi, Democratic Republic of Congo aimed to determine the factors that influence the use of maternal health services in the city. The study found that a significant proportion of women in Lubumbashi do not make use of healthcare services during pregnancy, childbirth, and postpartum. Factors such as being a first-time mother, having multiple previous deliveries, and having an unplanned pregnancy were associated with lower utilization of antenatal care (ANC) services. Women who did not use ANC were also less likely to use postnatal care (PNC) services. Additionally, women who had uncomplicated deliveries were less likely to use PNC services compared to those who had complications.

Based on these findings, the study suggests several recommendations to improve access to maternal health services and promote safe motherhood:

1. Reinforce women’s autonomy: Efforts should be made to empower women and promote their decision-making power regarding their own healthcare. This can be achieved through education and awareness programs that emphasize the importance of maternal health services and encourage women to seek care.

2. Improve information and communication: There is a need to enhance the information provided to women of childbearing age regarding the benefits of maternal health services, including family planning. Communication between the healthcare system and the community should be strengthened to ensure that accurate and relevant information reaches women and their families.

3. Enhance community participation: Engaging the community in promoting safe motherhood and the use of maternal health services is crucial. Community members can play a role in raising awareness, supporting pregnant women, and advocating for the importance of healthcare services.

4. Strengthen healthcare infrastructure: Adequate healthcare facilities and trained healthcare personnel are essential for providing quality maternal health services. Investments should be made to improve the availability and accessibility of healthcare facilities, especially in underserved areas.

5. Address barriers to access: Barriers such as distance, cost, and cultural beliefs need to be addressed to ensure that women can easily access and afford maternal health services. Strategies such as mobile clinics, community-based services, and financial support programs can help overcome these barriers.

By implementing these recommendations, it is expected that access to maternal health services in Lubumbashi and similar settings can be improved, leading to better maternal and child health outcomes.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations for improving access to maternal health in Lubumbashi, Democratic Republic of Congo:

1. Strengthen women’s autonomy: Empower women by providing them with information and resources to make informed decisions about their reproductive health. This can include promoting education and awareness about maternal health services, family planning, and safe motherhood practices.

2. Improve communication between healthcare system and community: Enhance communication channels between healthcare providers and the community to ensure that accurate and relevant information about maternal health services is disseminated. This can involve community outreach programs, health education campaigns, and the use of local media channels.

3. Enhance participation from the community: Involve the community in decision-making processes related to maternal health services. This can be done through community engagement initiatives, such as establishing community health committees or involving community leaders in advocating for maternal health.

4. Improve quality of care: Enhance the quality of maternal health services by ensuring that healthcare facilities have qualified healthcare personnel, adequate resources, and necessary equipment. This can involve training healthcare providers, improving infrastructure, and ensuring the availability of essential medicines and supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify specific indicators that reflect access to maternal health services, such as the percentage of women attending antenatal consultations, the percentage of deliveries assisted by qualified healthcare personnel, and the percentage of women attending postnatal consultations.

2. Collect baseline data: Gather data on the current status of these indicators in Lubumbashi. This can be done through surveys, interviews, and data collection from healthcare facilities.

3. Implement interventions: Implement the recommended interventions, such as strengthening women’s autonomy, improving communication, enhancing community participation, and improving quality of care. These interventions can be implemented over a defined period of time.

4. Monitor and evaluate: Continuously monitor the progress of the interventions and collect data on the indicators. This can involve regular data collection, surveys, and interviews with healthcare providers and community members.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on the indicators. This can involve statistical analysis, such as comparing pre- and post-intervention data, calculating percentages and proportions, and conducting regression analysis to determine the association between the interventions and the indicators.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health services. Make recommendations for further improvements or adjustments to the interventions based on the findings.

7. Repeat the process: Continuously repeat the monitoring and evaluation process to assess the long-term impact of the interventions and make further adjustments as needed.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health in Lubumbashi.

Author

Dima Health

Statistics:

Citations: 59

Identifiers:

DOI: 10.1186/1471-2393-12-66

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Congo, Kenya, Multi-Countries, Zambia

Study Design:

Case Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female