Predictors of institutional delivery service utilization among women of reproductive age in Senegal: a population-based study

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Study Justification:
– The study investigates the predictors of health facility-based delivery utilization in Senegal.
– It addresses the issue of low utilization of health facility delivery services in the country.
– The study aims to provide evidence on the determinants of health facility delivery in Senegal.
Highlights:
– Facility-based delivery utilization in Senegal was found to be 77.7%.
– The main predictors of health facility delivery utilization were maternal educational status, husband’s educational status, maternal occupation, ethnicity, place of residence, media exposure, economic status, parity, wife beating attitude, and skilled antenatal care.
– Women who were educated, exposed to media, wealthy, against wife-beating, attended skilled antenatal care, and had educated husbands were more likely to utilize health facility delivery services.
– On the other hand, women from ethnic groups like Poular, those working in agricultural activities, living in rural settings, and those with more delivery history were less likely to deliver at a health facility.
Recommendations:
– Empower women by encouraging them to use skilled antenatal care services to enhance their knowledge and utilization of health facility delivery.
– Remove socio-economic barriers to access health facility delivery, such as low education, poverty, and rural dwelling.
Key Role Players:
– Ministry of Health: Responsible for implementing policies and programs to improve maternal health and increase health facility delivery utilization.
– Health Facilities: Provide quality delivery services and ensure availability of skilled attendants.
– Community Health Workers: Educate and raise awareness among women about the benefits of health facility delivery and skilled antenatal care.
– Non-Governmental Organizations: Support initiatives to improve maternal health and increase health facility delivery utilization.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers.
– Awareness campaigns and community outreach programs.
– Infrastructure development and equipment for health facilities.
– Support for transportation services in rural areas.
– Monitoring and evaluation of interventions.
Please note that the cost items provided are general categories and not actual cost estimates. 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 strong, as it is based on a population-based study with a large sample size. The study used multivariable logistic regression analysis to identify statistically significant predictors. However, to improve the evidence, the abstract could provide more information on the sampling methodology and the representativeness of the sample. Additionally, it would be helpful to include information on the limitations of the study and potential sources of bias.

Background: In Senegal, sub-Saharan Africa, many women continue to die from pregnancy and childbirth complications. Even though health facility delivery is a key intervention to reducing maternal death, utilization is low. There is a dearth of evidence on determinants of health facility delivery in Senegal. Therefore, this study investigated the predictors of health facility-based delivery utilization in Senegal. Methods: Data from the 2017 Senegal Continuous Survey were extracted for this study, and approximately 11,487 ever-married women aged 15–49 years participated. Chi-square test was used to select significant variables and multivariable logistic regression analysis was performed to identify statistically significant predictors at a 95% confidence interval with a 0.05 p-value using Stata version 14 software. Results: Facility-based delivery utilization was 77.7% and the main predictors were maternal educational status (primary school Adjusted Odds Ratio [aOR] = 1.44, 95% CI; 1.14–1.83; secondary school aOR = 1.62, 95% CI; 1.17–2.25), husband’s educational status (primary school aOR = 1.65, 95% CI; 1.24–2.20, secondary school aOR = 2.17, 95% CI; 1.52–3.10), maternal occupation (agricultural-self-employed aOR = 0.77, 95% CI; 0.62–0.96), ethnicity (Poular aOR = 0.74, 95% CI; 0.56–0.97), place of residence (rural aOR = 0.57, 95% CI; 0.43, 0.74), media exposure (yes aOR = 1.26, 95% CI; 1.02–1.57), economic status (richest aOR = 5.27, 95% CI; 2.85–9.73), parity (seven and above aOR =0.46, 95% CI; 0.34–0.62), wife beating attitude (refuse aOR =1.23, 95% CI; 1.05–1.44) and skilled antenatal care (ANC) (yes aOR = 4.34, 95% CI; 3.10–6.08). Conclusion: Uptake of health facility delivery services was seen among women who were educated, exposed to media, wealthy, against wife-beating, attended ANC by skilled attendants and had educated husbands. On the other hand, women from ethnic groups like Poular, those working in agricultural activities, living in rural setting, and those who had more delivery history were less likely to deliver at a health facility. Therefore, there is the need to empower women by encouraging them to use skilled ANC services in order for them to gain the requisite knowledge they need to enhance their utilization of health facility delivery, whiles at the same time, removing socio-economic barriers to access to health facility delivery that occur from low education, poverty and rural dwelling.

Senegal, located in West Africa, is well-known as the “Entry to Africa” [32, 33]. Up to half of its 15.4 million people (as of 2016) live in and around Dakar and other urban areas [33]. Since 1960, three very non-violent political changes have taken place, ensuring its stability [34]. The nation’s economic growth, reported at 6% growth rate in 2018, looks promising for the future [34]. According to available data in 2011 by the World Bank, 38% of Senegal’s population lives on less than $1.90 per day [34]. Senegal’s health system is a hierarchical structure, with each of the 14 regional medical offices in charge of the provision and supervision of healthcare within the regions. There are also health districts which usually consist of one health center linked to rural health posts, some of which supervise the allied health huts [35]. There are also community-level facilities known as health huts, usually operated by a community health worker employed by community health committees [36]. We used the most recent (2017) Senegal Continuous Survey (SCS) for this analysis [37]. Sampling for the 2017 SCS was done using a stratified, two-stage cluster sampling design to provide estimates for essential population and health indicators for the country. Large geographic settings known as enumeration areas (EAs) were selected in the first stage through Probability Proportional to Size (PPS). The survey included a total of 8800 (4092 in urban areas and 4708 in rural) households and a total of 16,787 women (15–49 years of age) and 6977 Men (15–59 years of age) were interviewed [37]. Household listing was completed in each EA to ready the sampling frame. Selected participants were questioned using standard and country-specific questionnaire modules covering a wide range of health topics. For this study, we included 11,487 currently married women aged 15–49 years with a birth, for the most recent live births in the 5 years preceding the survey [37] from the kids (children) recode file (KR). The survey is publicly available on the DHS website (www.dhsprogram.com). Place of delivery was the outcome variable in this study and was grouped into health facility delivery (deliveries that occurred in a government hospital, government health center/maternity, government health post, mobile government clinic, government field worker, other public sector, private hospital/clinic and other private sectors) and non-health facility delivery (deliveries that occurred at respondents’ or relatives’ homes, or in other places like on the road). Births with missing information were added to the denominator for both the distribution of place of delivery and percentage of all births that occurred in a health facility. The percentage distribution of place of delivery included a separate category for missing values. Despite the fact that data were available for all live births to questioned women in the 5 years preceding the survey, we calculated for only the most recent birth as recommended by DHS guideline. Several individual and community level explanatory variables were incorporated from previous studies [17, 21, 23, 24, 38–43] due to their role in contributing to increase or decrease in the use of facility delivery. The independent variables were maternal age (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49), maternal educational status (no formal education, primary school, secondary school, higher), maternal occupation (not working, sales and services, agricultural-self-employed, other), husband education (no formal education, primary school, secondary school, higher), husband occupation (not working, professional/technical or managerial, sales and services, agricultural-self-employed, skilled manual, unskilled manual, other), religion (Muslim, Christian), ethnicity (Wolof, Poular, Serer, Mandingue/Soce, Diola, Soninke, other Senegalese, other), region (Dakar, Ziguinchor, Diourbel, Saint-Louis, Tambacounda, Kaolack, Thios, Louga, Fatick, Kolda, Matam, Kaffrine, Kedougou, Sedhiou), and wealth index (poorest, poorer, middle, richer, richest). We looked at media exposure (if the respondent was exposed to any of the three types; read newspaper, listened to radio or watched television for at least less than once a week it was coded as yes, and otherwise, no), place of residence (urban, rural), and parity (<=2, 3–4, 5–6, 7+). Decision making power was also included; we looked to see if the respondent had no decision-making power, she alone made decisions, or if she made decisions together with her husband. There were three decision making parameters; decision making about her health, to purchase large household items, to visit family/relatives. We coded “no decision making” if only the husband or other family members made decisions; we coded “decision making one” if the respondent had decision making power either alone or together with her husband on two of the above decision-making parameters; and we coded “decision making power two” if the respondent made decisions alone or together with her husband on all three decision making power parameters. Attitude toward wife beating was assessed as “refused” if the respondent disagreed with all five of the wife beating circumstances presented (burning the food while cooking, arguing with husband, going to visit family without husband permission, neglecting children, refusing to have sex with her husband), and “accepted” if she agreed to any of the five wife beating parameters. We included the use of skilled antenatal care (ANC); if the women had ANC follow up by a skilled attendant (i.e. doctor, midwife, nurse) we coded as yes, if not we coded as no. The participants’ socio-demographic characteristics were computed. Chi-square test was performed to identify variables that showed significant associations with the outcome variable at p-value less than 0.05 cut point. These variables were entered into the multivariable logistic regression model. Results of the multivariable logistic regression were reported using adjusted odds ratios (aORs) at a 95% confidence interval. Data was analyzed using Stata version 14 software (Stata Corp, College Station, Texas, USA). Weighting was applied using the guidelines provided in the user manual (https://www.dhsprogram.com/pubs/pdf/DHSG4/Recode7_DHS_10Sep2018_DHSG4.pdf), while the ‘SVY’ command was used to account for the complex sampling design. Since we used secondary data from SCS dataset which is available publicly, we did not need further ethical approval to use the data. However, in addition to obtaining the participants consent prior to survey, the ICF international strictly followed the ethical standards collaborating with the concerned country’s Ethical Review Board to ensure the DHS data collection process was in line with the U.S. Department of Health and Human Services regulations for the respect of the right of human subjects.

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

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to rural areas and provide essential maternal health services, including antenatal care, delivery assistance, and postnatal care.

2. Telemedicine: Introducing telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone calls, reducing the need for travel and increasing access to medical advice.

3. Community Health Workers: Expanding the role of community health workers in providing maternal health education, promoting the importance of skilled antenatal care, and facilitating referrals to health facilities for delivery.

4. Financial Incentives: Introducing financial incentives, such as cash transfers or subsidies, to encourage women from low-income backgrounds to seek skilled antenatal care and deliver at health facilities.

5. Education and Awareness Campaigns: Conducting targeted education and awareness campaigns to address cultural beliefs and misconceptions surrounding maternal health, promoting the benefits of health facility delivery, and encouraging women to seek skilled antenatal care.

6. Improving Infrastructure: Investing in the improvement of healthcare infrastructure, particularly in rural areas, by building more health facilities, equipping them with necessary resources, and ensuring access to essential maternal health services.

7. Strengthening Health Systems: Enhancing the capacity of health systems to provide quality maternal health services, including training healthcare professionals, improving supply chain management for essential medicines and equipment, and implementing quality assurance mechanisms.

These innovations aim to address the identified predictors of health facility-based delivery utilization in Senegal, such as maternal education, husband’s education, place of residence, economic status, media exposure, and skilled antenatal care. By implementing these innovations, it is hoped that access to maternal health services will be improved, leading to a reduction in maternal mortality and morbidity rates in Senegal.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health in Senegal:

1. Strengthening Skilled Antenatal Care (ANC) Services: Encourage and promote the use of skilled ANC services by providing comprehensive and quality care to pregnant women. This can be achieved by training and deploying more skilled attendants, such as doctors, midwives, and nurses, to rural areas where access to healthcare facilities is limited. Additionally, implementing community-based ANC programs and mobile clinics can help reach women in remote areas.

2. Empowering Women through Education: Focus on improving maternal educational status by providing educational opportunities for women, especially in rural areas. This can be done through initiatives that promote girls’ education, adult literacy programs, and vocational training. Educated women are more likely to seek and utilize healthcare services, including facility-based delivery.

3. Addressing Socio-economic Barriers: Implement interventions that address socio-economic barriers to accessing health facility delivery. This can include providing financial support or subsidies for transportation and healthcare costs, especially for women from low-income households. Additionally, creating income-generating opportunities for women, such as microfinance programs or vocational training, can help alleviate poverty-related barriers.

4. Enhancing Media Exposure: Increase media exposure and health education campaigns to raise awareness about the importance of facility-based delivery and the availability of maternal health services. This can be done through radio programs, television advertisements, and community outreach activities. Information should be provided in local languages and tailored to the specific cultural context of different regions in Senegal.

5. Promoting Gender Equality and Women’s Empowerment: Address gender norms and attitudes towards women’s decision-making power and rights. Promote programs that challenge harmful traditional practices, such as wife-beating, and empower women to make decisions about their own health and well-being. Engaging men and community leaders in these efforts is crucial for creating sustainable change.

By implementing these recommendations, it is expected that access to maternal health services, including facility-based delivery, will improve in Senegal, leading to a reduction in maternal mortality and improved health outcomes for women and their newborns.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health in Senegal:

1. Increase maternal educational opportunities: Promote and provide access to education for women, particularly at the primary and secondary school levels. This can empower women with knowledge and information about maternal health, leading to increased utilization of health facility delivery services.

2. Improve husband’s educational status: Implement programs and initiatives to improve the educational status of husbands, as it has been identified as a predictor of health facility delivery utilization. Educated husbands may be more supportive of their wives seeking skilled antenatal care and delivering at health facilities.

3. Enhance media exposure: Increase media exposure among women, particularly in rural areas, to disseminate information about the importance of health facility delivery and skilled antenatal care. This can be done through radio programs, television campaigns, and newspaper articles.

4. Address socio-economic barriers: Implement strategies to address socio-economic barriers that hinder access to health facility delivery, such as poverty and low education. This can include providing financial support for transportation to health facilities and offering incentives for women to seek skilled antenatal care.

5. Empower women in decision-making: Promote women’s decision-making power in matters related to their health, including decisions about seeking skilled antenatal care and delivering at health facilities. This can be achieved through awareness campaigns and community engagement programs.

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

1. Data collection: Collect data on the current utilization of health facility delivery services, including information on socio-economic factors, educational status, media exposure, and decision-making power among women.

2. Identify predictors: Analyze the collected data to identify the predictors that significantly influence health facility delivery utilization. This can be done using statistical techniques such as logistic regression.

3. Develop a simulation model: Develop a simulation model that incorporates the identified predictors and their impact on health facility delivery utilization. This model should consider the interplay between different factors and their potential effects on access to maternal health.

4. Simulate interventions: Introduce the recommended interventions into the simulation model and assess their potential impact on improving access to maternal health. This can be done by adjusting the values of relevant variables based on the expected effects of the interventions.

5. Evaluate outcomes: Evaluate the outcomes of the simulation, including changes in health facility delivery utilization rates and any associated improvements in maternal health outcomes. This evaluation can be done by comparing the simulated results with the baseline data.

6. Refine and iterate: Refine the simulation model based on the evaluation results and iterate the process to further optimize the interventions and their impact on improving access to maternal health.

It is important to note that the methodology described above is a general framework and may require customization based on the specific context and available data in Senegal.

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