Who delivers where? The effect of obstetric risk on facility delivery in East Africa

Abstract

Abstractobjectives Skilled attendance at birth is key for the survival of pregnant women. This study investigates whether women at increased risk of maternal and newborn complications in four East African countries are more likely to deliver in a health facility than those at lower risk.methods Demographic and Health Survey data for Kenya 2014, Rwanda 2014-15, Tanzania 2015 and Uganda 2011 were used to study women with a live birth in the three years preceding the survey. A three-level obstetric risk index was created using known risk factors. Generalised linear Poisson regression was used to investigate the association between obstetric risk and facility delivery.results We analysed data from 13 119 women across the four countries of whom 42-45% were considered at medium risk and 12-17% at high risk, and the remainder were at low risk. In Rwanda, 93% of all women delivered in facilities but this was lower (59-66%) in the other three countries.There was no association between a woman's obstetric risk level and her place of delivery in any country; greater wealth and more education were, however, independently strongly associated with facility delivery.conclusions In four East African countries, women at higher obstetric risk were not more likely to deliver in a facility than those with lower risk. This calls for a renewed focus on antenatal risk screening and improved communication on birth planning to ensure women with an increased chance of maternal and newborn complications are supported to deliver in facilities with skilled care.

Correlates of facility-based delivery among women of reproductive age from the Digo community residing in Kwale, Kenya

“…Different studies have revealed various barriers associated with this disparity including traditional and familial influences, high costs, low perceived quality of care and fear of discrimination during facility-based delivery [ 3 , 13 – 16 ]. Women who have otherwise attended ANC well have reported fearing poor quality of services during childbirth which makes them prefer a home delivery [ 17 – 19 ].…”

What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal

“…Subnational budgets should prioritise paving roads from health posts to main roads, and additional interventions should be trialled, including strategically placed shared ambulances and maternity waiting homes adjacent to health centres and hospitals 22 68 69. Strengthening antenatal care would enable referral to higher-level facilities for women with preidentifiable conditions (including twin pregnancy and pre-eclampsia) 70–72. The extent of informal use of health services between Senegal and neighbouring Gambia is unknown; however, providers in Senegal are unable to refer to facilities in the Gambia, even if those are nearer: reciprocal formal arrangements between these countries for obstetric emergencies should be considered.…”

Redesigning maternal health services: is centralisation the answer in low-resource settings?

“…One side-effect of this policy shift was the neglect of the identification of high-risk pregnancies through antenatal care and referral to higher level care 14. The fact that some mothers and babies face substantially greater risks, as with twins, premature birth or previous caesarean section,15 is a central aspect of all childbirth care systems in high-income countries.…”

“…In low perinatal mortality settings, we see continuous developments to more specialised care, improved triaging to allow low-risk pregnancies to have safe midwifery-led care, backed by functioning emergency referral. This triaging and referral is largely absent in low-resource settings, and the lack of the identification of pregnancies which are at very high risk might be one reason for the slow decline in maternal and perinatal mortality 14 16…”