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Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis

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      Abstract

      Background

      Improving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC).

      Methods

      This study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study.

      Results

      The results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mother's education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services.

      Conclusions

      We found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions.

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      Most cited references 8

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      Still too far to walk: Literature review of the determinants of delivery service use

      Background Skilled attendance at childbirth is crucial for decreasing maternal and neonatal mortality, yet many women in low- and middle-income countries deliver outside of health facilities, without skilled help. The main conceptual framework in this field implicitly looks at home births with complications. We expand this to include "preventive" facility delivery for uncomplicated childbirth, and review the kinds of determinants studied in the literature, their hypothesized mechanisms of action and the typical findings, as well as methodological difficulties encountered. Methods We searched PubMed and Ovid databases for reviews and ascertained relevant articles from these and other sources. Twenty determinants identified were grouped under four themes: (1) sociocultural factors, (2) perceived benefit/need of skilled attendance, (3) economic accessibility and (4) physical accessibility. Results There is ample evidence that higher maternal age, education and household wealth and lower parity increase use, as does urban residence. Facility use in the previous delivery and antenatal care use are also highly predictive of health facility use for the index delivery, though this may be due to confounding by service availability and other factors. Obstetric complications also increase use but are rarely studied. Quality of care is judged to be essential in qualitative studies but is not easily measured in surveys, or without linking facility records with women. Distance to health facilities decreases use, but is also difficult to determine. Challenges in comparing results between studies include differences in methods, context-specificity and the substantial overlap between complex variables. Conclusion Studies of the determinants of skilled attendance concentrate on sociocultural and economic accessibility variables and neglect variables of perceived benefit/need and physical accessibility. To draw valid conclusions, it is important to consider as many influential factors as possible in any analysis of delivery service use. The increasing availability of georeferenced data provides the opportunity to link health facility data with large-scale household data, enabling researchers to explore the influences of distance and service quality.
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        Bringing context back into epidemiology: variables and fallacies in multilevel analysis.

        A large portion of current epidemiologic research is based on methodologic individualism: the notion that the distribution of health and disease in populations can be explained exclusively in terms of the characteristics of individuals. The present paper discusses the need to include group- or macro-level variables in epidemiologic studies, thus incorporating multiple levels of determination in the study of health outcomes. These types of analyses, which have been called contextual or multi-level analyses, challenge epidemiologists to develop theoretical models of disease causation that extend across levels and explain how group-level and individual-level variables interact in shaping health and disease. They also raise a series of methodological issues, including the need to select the appropriate contextual unit and contextual variables, to correctly specify the individual-level model, and, in some cases, to account for residual correlation between individuals within contexts. Despite its complexities, multilevel analysis holds potential for reemphasizing the role of macro-level variables in shaping health and disease in populations.
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          Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities.

          Appropriate antenatal care is important in identifying and mitigating risk factors in pregnancy but many mothers in the developing world do not receive such care. This paper uses data from the 1993 Kenya Demographic and Health Survey to study the variations in the use of antenatal services in Kenya. The analysis is based on modelling the frequency and timing of antenatal visits using three-level linear regression models. The results show that the use of antenatal care in Kenya is associated with a range of socio-economic, cultural and reproductive factors. The availability and accessibility of health services and the desirability of a pregnancy are also important. Use of antenatal care is infrequent for unwanted and mistimed pregnancies; even women who use antenatal care frequently appear to be less consistent if a pregnancy is mistimed. The results also indicate that women are highly consistent in the use of antenatal care during pregnancies. The intra-woman correlation coefficient for the frequency of antenatal visits ranges between 50% and 80% with greater correlation for wanted pregnancies to women in urban areas.
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            Author and article information

            Affiliations
            [1 ]United Nations Population Fund, Bhopal, Madhya Pradesh-462013, India
            [2 ]Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE-90187, Sweden
            Contributors
            Journal
            Int J Equity Health
            International Journal for Equity in Health
            BioMed Central
            1475-9276
            2011
            5 December 2011
            : 10
            : 59
            3283453
            1475-9276-10-59
            22142036
            10.1186/1475-9276-10-59
            Copyright ©2011 Jat et al; licensee BioMed Central Ltd.

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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