Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi

Abstract

IntroductionIn the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women’s choice of delivery facility.MethodsA revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion.ResultsTwo classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women.ConclusionFor only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

“…This may lead to increasing gaps between socioeconomic groups and exacerbate the urban–rural divide in access to essential social services. 53 54 Finally, weak health systems may struggle with the ‘capability trap’: donor and political pressure to rapidly appear capable, despite a lack of capacity to implement policy and programmes. 55 Relabelled but not redesigned systems will not achieve improvements in maternal and neonatal health.…”

Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis

“…Each woman's choice was modelled as a two-step process, on the basis of the choice function published by Yorlets and colleagues 12 . The choice function was based on discrete-choice methodology applied to the women in the Millennium Development Goal Endline Survey and the 540 possible delivery facilities where they could give birth.…”

“…All delivery facilities within 100 km of a woman were included in her choice set. Factors influencing each woman's facility selection were the following: facility type, basic obstetric readiness score, road distance, and whether the facility charged fees for delivery 12 . We calculated the probability of delivery at each facility and the woman was then assigned, probabilistically, to deliver at a single facility.…”

“…The secondary outcome was the assessment of individual utility. Outputs of the status quo scenario were compared with the known joint distribution of wealth and location in Malawi, the distribution of maternal delivery across facility types, and the estimated preference class breakdown from Yorlets and colleagues 12 …”

“…However, evidence for or against regionalisation for more common procedures, such as obstetric delivery, is sparse, especially in low-resource settings. Additionally, a latent class analysis 12 of obstetric care in Malawi suggested that policies to connect women to high-quality delivery services should consider the strong preference of most women for care that is close and free.…”