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

Abstract

BackgroundSkilled 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.MethodsWe 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.ResultsThere 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.ConclusionStudies 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.

Challenges in day-to-day midwifery practice; a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania

“…Increased knowledge in itself has been documented to increase rates of facility-assisted deliveries, which in turn will have a positive effect on both mother and child mortality [28]. Higher levels of education have been shown to increase the use of delivery services [29]. Focusing on a general increase in education in the region, with emphasis on awareness of danger signs during pregnancy and delivery [30], might therefore have an effect on birth outcome, and help eliminate the problem of seeking professional help too late.…”

Persistent inequity in maternal health care utilization in Nepal despite impressive overall gains

“…Issues such as why women who attend antenatal care do not follow through and deliver at a facility or with a skilled provider need to be investigated, and more emphasis on facility delivery and its advantages need to be placed early during ANC. Experiences of care previously received, including being subject to disrespect and abuse, influence the decision to seek care [22] and therefore further studies investigating mothers’ perceptions of care received are needed.…”

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

“…38,40 Additionally, geographical access to facilities can be an important determinant of use. 45 One review 46 of largescale, compre hensive primary health-care initiatives showed that establish ment of a network of primary-care facilities can have an important eff ect on increasing coverage in underserved rural populations in particular.…”