Determinants of institutional delivery in Sub-Saharan Africa: findings from Demographic and Health Survey (2013–2017) from nine countries

  • Tropical Medicine and Health, Volume 49, No. 1, Year 2021

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Study Justification:
The study aimed to investigate the factors influencing women’s decision to use institutional delivery services in Sub-Saharan Africa (SSA). This is important because institutional delivery is crucial for a country’s long-term growth, and SSA countries face challenges such as rapid population development, illiteracy, large families, and disparities in urban-rural health facilities that affect institutional services.
Highlights:
1. Rural vs Urban Residence: Women living in rural areas were less likely to use institutional delivery services compared to those in urban areas.
2. Education: Women with primary education or higher were more likely to deliver in health institutes compared to non-educated women.
3. Age: Women aged 35-49 years were more likely to give birth in health centers compared to women under 24 years.
4. Antenatal Care (ANC) Visits: Women who visited health facilities for ANC four or more times were more likely to deliver in health institutes.
5. Distance to Health Facility: The distance from home to a health facility was not a significant factor in the preference for institutional delivery.
6. Media Exposure: Women with media exposure were more likely to deliver in health institutions compared to non-media-exposed women.
Recommendations:
1. Improve Educational Level: Efforts should be made to improve the educational level of women, as higher education was associated with a higher likelihood of using institutional delivery services.
2. Address Urban-Rural Disparities: The gap between urban and rural health facilities needs to be narrowed to ensure equal access to institutional delivery services.
3. Increase Health Facilities: The number of health facilities should be increased to accommodate the demand for institutional delivery services.
4. Awareness Campaigns: Create awareness among women about the advantages of visiting and giving birth in health facilities to encourage institutional delivery.
Key Role Players:
1. Government Health Ministries: Responsible for implementing policies and strategies to improve institutional delivery services.
2. Non-Governmental Organizations (NGOs): Can provide support and resources to address the challenges and implement awareness campaigns.
3. Health Professionals: Including doctors, nurses, and midwives, who play a crucial role in providing quality maternal healthcare services.
4. Community Leaders: Engaging community leaders can help in spreading awareness and encouraging women to use institutional delivery services.
Cost Items for Planning Recommendations:
1. Education Programs: Budget for initiatives aimed at improving the educational level of women.
2. Infrastructure Development: Funds for building and upgrading health facilities in both urban and rural areas.
3. Training and Capacity Building: Allocate resources for training healthcare professionals to provide quality maternal healthcare services.
4. Awareness Campaigns: Budget for media campaigns, community outreach programs, and educational materials to raise awareness about the benefits of institutional delivery.
Please note that the cost items mentioned are general categories and the actual cost will depend on the specific context and implementation strategies.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is rated 8 because it provides specific findings from a recent Demographic and Health Survey (DHS) conducted in nine Sub-Saharan African countries. The study uses logistic regression models to determine the factors influencing women’s decision to use institutional delivery services. The odds ratios and confidence intervals are provided for various factors such as rural vs urban residence, education level, age, number of ANC visits, distance to health facility, and media exposure. The study concludes that women over 24, with primary education or higher, urban residents, fewer children, never married, higher number of prenatal care visits, higher economic level, mass-media exposure, and living with educated husbands are more likely to deliver in health facilities. The abstract also suggests actionable steps to improve institutional delivery, such as addressing the gap between urban and rural health facilities, improving women’s education, increasing the number of health facilities, and creating awareness about the advantages of delivering in health facilities. To improve the evidence, the abstract could provide more details about the methodology used in the logistic regression models, such as the inclusion of control variables and model fit statistics. Additionally, it would be helpful to include the sample size and representativeness of the survey data, as well as any limitations or potential biases in the study.

Introduction: Institutional delivery is a major concern for a country’s long-term growth. Rapid population development, analphabetism, big families, and a wider range of urban-rural health facilities have had a negative impact on institutional services in Sub-Saharan Africa (SSA) countries. The aim of this study was to look into the factors that influence women’s decision to use an institutional delivery service in SSA. Methods: The most recent Demographic and Health Survey (DHS), which was conducted in nine countries (Senegal, Ethiopia, Malawi, Rwanda, Tanzania, Zambia, Namibia, Ghana, the Democratic Republic of Congo) was used. The service’s distribution outcome (home delivery or institutional delivery) was used as an outcome predictor. Logistic regression models were used to determine the combination of delivery chances and different covariates. Results: The odds ratio of the experience of institutional delivery for women living in rural areas vs urban area was 0.44 (95% confidence interval (CI) 0.41–0.48). Primary educated women were 1.98 (95% CI 1.85–2.12) times more likely to deliver in health institutes than non-educated women, and secondary and higher educated women were 3.17 (95% CI 2.88–3.50) times more likely to deliver in health centers with facilities. Women aged 35–49 years were 1.17 (95% CI 1.05–1.29) times more likely than women aged under 24 years to give birth in health centers. The number of ANC visits: women who visited four or more times were 2.98 (95% CI 2.77–3.22) times, while women who visited three or less times were twice (OR = 2.03; 95% CI 1.88–2.18) more likely to deliver in health institutes. Distance from home to health facility were 1.18 (95% CI 1.11–1.25) times; media exposure had 1.28 (95% CI 1.20–1.36) times more likely than non-media-exposed women to delivery in health institutions. Conclusions: Women over 24, primary education at least, urban residents, fewer children, never married (living alone), higher number of prenatal care visits, higher economic level, have a possibility of mass-media exposure and live with educated husbands are more likely to provide health care in institutions. Additionally, the distance from home to a health facility is not observed widely as a problem in the preference of place of child delivery. Therefore, due attention needs to be given to address the challenges related to narrowing the gap of urban-rural health facilities, educational level of women improvement, increasing the number of health facilities, and create awareness on the advantage of visiting and giving birth in health facilities.

We use data from the most recent Demographic and Health Survey (DHS) to collect institutional delivery services data from nine countries: Senegal in 2017, Ethiopia in 2016, Malawi in 2016, Rwanda in 2015, Tanzania in 2016, Zambia in 2014, Namibia in 2013, Ghana in 2014, and the Democratic Republic of Congo in 2014 (Table ​(Table11). Year of survey and number of women in the nine Sub-Saharan Africa using Demographic and Health Surveys 2013–2017 The countries were chosen based on data availability and historical significance. Measure DHS gave the authors permission to download and use these data for this report. The DHS survey was a cross-sectional study that used stratified multistage (mostly two-stage) cluster sampling to sample people across the country. The Population and Housing Census (PHC) sampling frames were used in the Enumeration Areas (PHC). It had been used as a preliminary cluster sampling method. Random samples of households were taken in the second stage of clustering within each cluster. All subpopulations are fairly represented in the survey results. The DHS data are open to the public and provide information on maternal, infant, and child mortality, as well as socio-demographic, economic, and health-related variables. We obtained the information from the DHS, which included the location of birth for mothers aged 15 to 49 years, as determined by sampled households in each cluster unit. The woman questionnaire was used to obtain the dependent variable, which is the place of delivery. The data was gathered from qualified women aged 15 to 49 years old, who were asked questions about their socio-demographic and economic backgrounds (age, sex, education, marital status, and income), birth history, health facility, media exposure, antenatal visits, women and their husbands’ job status, and other topics. The dependent variable in this study was registered as a dichotomous variable: home delivery (no) and institutional delivery (yes). The residence of the families residing in; fathers’ and mothers’ educational status; women’s age (in years at the time of the survey); the number of living children inside the family; the existence of mothers’ occupation; the household head; the income index; the number of antenatal care (ANC) visits during the pregnancy; the distance between home and health facilities; women’s marital status (at the time of the survey); and access to mass media were all considered independent variables. The independent variables are used because they are available in the dataset and have been studied previously. The independent variables were categorize to make the study simpler (Table ​(Table22). Relationship between correlates and place of delivery in nine Sub-Saharan Africa *Single, widowed, divorced The relation between the odds of the place of delivery and the aforementioned explanatory variables was estimated using Pearson chi-square (X2) and logistic regression models. STATA 14 was used to perform the data analysis. At the univariable point, the chi-square test of association was used to statistically test whether there was a meaningful association between the place of delivery and other explanatory categorical variables or not. As an outcome to the logistic regression model, a binary outcome (home delivery (no) or institutional delivery (yes) is used. The availability of a meaningful effect or correlation of independent variables with the outcome variable is tested using a p-value less than 0.05 or 5%. The data analyses conducted using the publicly available data of the 2013–2017 DHS of nine Sub-Saharan African countries (https://dhsprogram.com/Data/terms-of-use.cfm). The DHS program has given a written permission letter.

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The study titled “Determinants of institutional delivery in Sub-Saharan Africa: findings from Demographic and Health Survey (2013–2017) from nine countries” provides valuable insights into the factors influencing women’s decision to use institutional delivery services in Sub-Saharan Africa. Based on the study’s conclusions, the following recommendations can be developed into innovations to improve access to maternal health:

1. Narrowing the gap between urban and rural health facilities: Efforts should be made to improve the availability and quality of health facilities in rural areas. This can be achieved through the establishment of mobile clinics, telemedicine services, or the expansion of existing health facilities.

2. Improving women’s education: Initiatives should focus on increasing access to education for women, especially in rural areas, to empower them to make informed decisions about their maternal health.

3. Increasing the number of health facilities: There is a need to increase the number of health facilities, particularly in underserved areas. This can be achieved through infrastructure development and investment in healthcare resources.

4. Creating awareness about the benefits of institutional delivery: Efforts should be made to educate communities about the advantages of delivering in health facilities, such as access to skilled healthcare professionals, emergency obstetric care, and postnatal support. This can be done through community outreach programs, health campaigns, and the use of mass media.

5. Enhancing antenatal care (ANC) services: Strengthening ANC services is crucial, ensuring that pregnant women receive comprehensive care, including health education, screenings, and early detection of complications.

6. Addressing the distance barrier: While the study found that distance was not a significant factor in the preference for institutional delivery, efforts should still be made to improve transportation infrastructure and provide affordable transportation options for pregnant women, especially in remote areas.

By implementing these recommendations, policymakers, healthcare providers, and communities can work together to improve access to maternal health services and ultimately reduce maternal mortality rates in Sub-Saharan Africa.
AI Innovations Description
The study titled “Determinants of institutional delivery in Sub-Saharan Africa: findings from Demographic and Health Survey (2013–2017) from nine countries” provides valuable insights into the factors influencing women’s decision to use institutional delivery services in Sub-Saharan Africa. Based on the study’s conclusions, the following recommendations can be developed into innovations to improve access to maternal health:

1. Narrowing the gap between urban and rural health facilities: Given that women living in rural areas are less likely to opt for institutional delivery, efforts should be made to improve the availability and quality of health facilities in rural areas. This can be achieved through the establishment of mobile clinics, telemedicine services, or the expansion of existing health facilities.

2. Improving women’s education: The study found that women with primary and higher education were more likely to deliver in health facilities. Therefore, initiatives should focus on increasing access to education for women, especially in rural areas, to empower them to make informed decisions about their maternal health.

3. Increasing the number of health facilities: To accommodate the growing population and ensure adequate access to maternal health services, there is a need to increase the number of health facilities, particularly in underserved areas. This can be achieved through infrastructure development and investment in healthcare resources.

4. Creating awareness about the benefits of institutional delivery: Efforts should be made to educate communities about the advantages of delivering in health facilities, such as access to skilled healthcare professionals, emergency obstetric care, and postnatal support. This can be done through community outreach programs, health campaigns, and the use of mass media.

5. Enhancing antenatal care (ANC) services: The study found that women who had more ANC visits were more likely to deliver in health facilities. Therefore, it is crucial to strengthen ANC services, ensuring that pregnant women receive comprehensive care, including health education, screenings, and early detection of complications.

6. Addressing the distance barrier: The study revealed that the distance between home and health facilities was not a significant factor in the preference for institutional delivery. However, efforts should still be made to improve transportation infrastructure and provide affordable transportation options for pregnant women, especially in remote areas.

By implementing these recommendations, policymakers, healthcare providers, and communities can work together to improve access to maternal health services and ultimately reduce maternal mortality rates in Sub-Saharan Africa.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Narrowing the gap between urban and rural health facilities: Simulate the establishment of mobile clinics and telemedicine services in rural areas. This can be done by identifying areas with limited access to health facilities and determining the number and location of mobile clinics needed to bridge the gap. Additionally, simulate the expansion of existing health facilities in rural areas by assessing the infrastructure requirements and estimating the cost and feasibility of such expansions.

2. Improving women’s education: Simulate initiatives to increase access to education for women, especially in rural areas. This can be done by estimating the number of schools and teachers needed to accommodate the target population and assessing the resources required for educational programs. Additionally, simulate the impact of providing scholarships or financial incentives to encourage women to pursue higher education.

3. Increasing the number of health facilities: Simulate the establishment of new health facilities in underserved areas. This can be done by identifying areas with inadequate access to health facilities and determining the number and location of new facilities needed. Simulate the infrastructure development and investment required to establish these facilities, including the construction of buildings, procurement of medical equipment, and recruitment of healthcare professionals.

4. Creating awareness about the benefits of institutional delivery: Simulate community outreach programs, health campaigns, and mass media initiatives to educate communities about the advantages of delivering in health facilities. This can be done by estimating the reach and impact of these initiatives, such as the number of people reached, changes in knowledge and attitudes, and subsequent increase in institutional delivery rates.

5. Enhancing antenatal care (ANC) services: Simulate the strengthening of ANC services by assessing the resources required to provide comprehensive care, including health education, screenings, and early detection of complications. Estimate the impact of increasing the number of ANC visits and improving the quality of care on the likelihood of delivering in health facilities.

6. Addressing the distance barrier: Simulate improvements in transportation infrastructure and the provision of affordable transportation options for pregnant women in remote areas. This can be done by estimating the cost and feasibility of infrastructure projects, such as road construction or transportation subsidies, and assessing the potential increase in institutional delivery rates resulting from improved access to health facilities.

By simulating these recommendations, policymakers and stakeholders can assess the potential impact of each intervention on improving access to maternal health services in Sub-Saharan Africa. This can help inform decision-making, resource allocation, and the development of effective strategies to reduce maternal mortality rates in the region.


Statistics:
Citations: 3
Identifiers:
DOI: 10.1186/s41182-021-00335-x
ISSN: 13488945
Research Areas:
Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations
Study Countries:
Congo, Ethiopia, Ghana, Malawi, Multi-Countries, Namibia, Rwanda, Senegal, Tanzania, Zambia
Study Design:
Case-Control Study, Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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