SummaryBackground Stillbirths do not count in routine worldwide data-collating systems or for the Millennium Development Goals. Two sets of national stillbirth estimates for 2000 produced similar worldwide totals of 3·2 million and 3·3 million, but rates diff ered substantially for some countries. We aimed to develop more reliable estimates and a time series from 1995 for 193 countries, by increasing input data, using recent data, and applying improved modelling approaches.
In Tanzania, the coverage of four or more antenatal care (ANC 4) visits among pregnant women has declined over time. We conducted an exploratory analysis to identify factors associated with utilization of ANC 4 and ANC 4 decline among pregnant women over time. We used data from 8035 women who delivered within two years preceding Tanzania Demographic and Health Surveys conducted in 1999, 2004/05 and 2010. Multivariate logistic regression models were used to examine the association between all potential factors and utilization of ANC 4; and decline in ANC 4 over time. Factors positively associated with ANC 4 utilization were higher quality of services, testing and counseling for HIV during ANC, receiving two or more doses of SP (Sulphadoxine Pyrimethamine)/Fansidar for preventing malaria during ANC and higher educational status of the woman. Negatively associated factors were residing in a zone other than Eastern zone, never married woman, reported long distance to health facility, first ANC visit after four months of pregnancy and woman's desire to avoid pregnancy. The factors significantly associated with decline in utilization of ANC 4 were: geographic zone and age of the woman at delivery. Strategies to increase ANC 4 utilization should focus on improvement in quality of care, geographic accessibility, early ANC initiation, and services that allow women to avoid pregnancy. The interconnected nature of the Tanzanian Health System is reflected in ANC 4 decline over time where introduction of new programs might have had unintended effects on existing programs. An in-depth assessment of the recent policy change towards Focused Antenatal Care and its implementation across different geographic zones, including its effect on the perception and understanding among women and performance and counseling by health providers can help explain the decline in ANC 4.
The intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.
BackgroundPostnatal care (PNC) for the mother and infant is a neglected area, even for women who give birth in a health facility. Currently, there is very little evidence on the determinants of use of postnatal care from health facilities in Tanzania.MethodsThis study examined the role of individual and community-level variables on the use of postnatal health services, defined as a check up from a heath facility within 42 days of delivery, using multilevel logistic regression analysis. We analyzed data of 1931 women, who had delivered in the preceding 2–14 months, from a two-stage household survey in 4 rural districts of Morogoro region, Tanzania. Individual level explanatory variables included i) Socio-demographic factors: age, birth order, education, and wealth, ii) Factors related to pregnancy: frequency of antenatal visits, history of complications, mode of delivery, place of delivery care, and counseling received. Community level variables included community levels of family planning, health service utilization, trust, poverty and education, and distance to health facility.ResultsLess than one in four women in Morogoro reported having visited a health facility for postnatal care. Individual-level attributes positively associated with postnatal care use were women’s education of primary level or higher [Odds Ratio (OR) 1.37, 95 % Confidence Interval (CI) 1.04–1.81], having had a caesarean section or forceps delivery (2.95, 1.8–4.81), and being counseled by a community health worker to go for postnatal care at a health facility (2.3, 1.36–3.89). Other positive associations included those recommended HIV testing for baby (1.94, 1.19–3.15), and whose partners tested for HIV (1.41, 1.07–1.86). High community levels of postpartum family planning usage (2.48, 1.15–5.37) and high level of trust in health system (1.77, 1.12–2.79) were two significant community-level predictors. Lower postnatal care use was associated with having delivered at a hospital (0.5, 0.33–0.76), health center (0.57, 0.38–0.85), or dispensary (0.48, 0.33–0.69), and having had severe swelling of face and legs during pregnancy (0.65, 0.43–0.97).ConclusionsIn the context of low postnatal care use in a rural setting, programs should direct efforts towards reaching women who do not avail themselves of postnatal care as identified in our study.
BackgroundThere is increasing evidence throughout the world that the negative treatment of pregnant women during labor and delivery can be a barrier to seeking skilled maternity care. At this time, there has been little quantitative evidence published on disrespect and abuse (D&A) in Malawi. The objective of this research is to describe the prevalence of disrespect and abuse during labor and delivery through the secondary analysis of direct clinical observations and to describe the association between the observation of D&A items with the place of delivery and client background characteristics.MethodsAs part of the evaluation of the Helping Babies Breathe intervention, direct observations of labor and delivery were conducted in August 2013 from 27 out of the 28 districts in Malawi. Frequencies of disrespect and abuse items organized around the Bowser and Hill categories of disrespect and abuse and presented in the White Ribbon Alliance’s Universal Rights of Childbearing Women Framework were calculated. Bivariate analysis was done to assess the association between selected client background characteristics and the place of delivery with the disrespect and use during childbirth.ResultsA total of 2109 observations were made across 40 facilities (12 health centers and 28 hospitals) in Malawi. The results showed that while women were frequently greeted respectfully (13.9% were not), they were often not encouraged to ask the health provider questions (73.1%), were not given privacy (58.2%) and were not encouraged to have a support person present with them (83.2%). Results from the bivariate analysis did not show a consistent relationship between place of delivery and D&A items, where the odds of being shouted at was lower in a health center when compared to a hospital (OR: 0.19; CI: 0.59–0.62) while there was a higher odds of clients not being asked if they have any concerns if they were in a health center when compared to a hospital (OR: 2.40; CI: 1.06–5.44). Women who were HIV+ had significantly lower odds of not having audio and visual privacy (OR: 0.34, CI: 0.12–0.97), of not being asked about her preferred delivery position (OR: 0.17, CI: 0.05–0.65) and of not being asked if she has any other problems she is concerned about (OR 0.38, CI:0.15–0.96).ConclusionThis study is among the first to quantify the prevalence of disrespect and abuse during labor and delivery in Malawi through direct clinical observations. Measurement of the poor treatment of women during childbirth is essential for understanding the scope of the problem and how to address this issue.
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