Bibha Simkhada

Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature

AIM This paper is a report of a systematic review to identify and analyse the main factors affecting the utilization of antenatal care in developing countries. BACKGROUND Antenatal care is a key strategy for reducing maternal mortality, but millions of women in developing countries do not receive it. DATA SOURCES A range of electronic databases was searched for studies conducted in developing countries and published between 1990 and 2006. English-language publications were searched using relevant keywords, and reference lists were hand-searched. REVIEW METHODS A systematic review was carried out and both quantitative and qualitative studies were included. RESULTS Twenty-eight papers were included in the review. Studies most commonly identified the following factors affecting antenatal care uptake: maternal education, husbands education, marital status, availability, cost, household income, womens employment, media exposure and having a history of obstetric complications. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Parity had a statistically significant negative effect on adequate attendance. Whilst women of higher parity tend to use antenatal care less, there is interaction with womens age and religion. Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them. CONCLUSION More qualitative research is required to explore the effect of womens satisfaction, autonomy and gender role in the decision-making process. Adequate utilization of antenatal care cannot be achieved merely by establishing health centres; womens overall (social, political and economic) status needs to be considered.

The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study

BackgroundAntenatal care (ANC) has been recognised as a way to improve health outcomes for pregnant women and their babies. However, only 29% of pregnant women receive the recommended four antenatal visits in Nepal but reasons for such low utilisation are poorly understood. As in many countries of South Asia, mothers-in-law play a crucial role in the decisions around accessing health care facilities and providers. This paper aims to explore the mother-in-laws role in (a) her daughter-in-laws ANC uptake; and (b) the decision-making process about using ANC services in Nepal.MethodsIn-depth interviews were conducted with 30 purposively selected antenatal or postnatal mothers (half users, half non-users of ANC), 10 husbands and 10 mothers-in-law in two different (urban and rural) communities.ResultsOur findings suggest that mothers-in-law sometime have a positive influence, for example when encouraging women to seek ANC, but more often it is negative. Like many rural women of their generation, all mothers-in-law in this study were illiterate and most had not used ANC themselves. The main factors leading mothers-in-law not to support/encourage ANC check ups were expectations regarding pregnant women fulfilling their household duties, perceptions that ANC was not beneficial based largely on their own past experiences, the scarcity of resources under their control and power relations between mothers-in-law and daughters-in-law. Individual knowledge and social class of the mothers-in-law of users and non-users differed significantly, which is likely to have had an effect on their perceptions of the benefits of ANC.ConclusionMothers-in-law have a strong influence on the uptake of ANC in Nepal. Understanding their role is important if we are to design and target effective community-based health promotion interventions. Health promotion and educational interventions to improve the use of ANC should target women, husbands and family members, particularly mothers-in-law where they control access to family resources.

Mental health issues in pregnant women in Nepal

Mental health of pregnant women and new mothers is a growing area of concern in both low- and high-income countries. Maternity services in the UK, for example, have focused more attention on maternal mental health. We recognise that pregnancy, birth and the postnatal period is a time of major psychological and social change for women.

Why do costs act as a barrier in maternity care for some, but not all women? A qualitative study in rural Nepal

Purpose - – The purpose of this paper is to analyse cost as a barrier to the uptake of antenatal care (ANC) in rural Nepal amidst a variety of barriers and facilitators. Design/methodology/approach - – A qualitative study with face-to-face interviews were conducted with 50 ANC users and non-users participants. The setting is rural Nepal, some 20 kilometres outside the capital Kathmandu. Interviews were audiotaped, transcribed and translated into English and results were presented thematically. Findings - – Cost was sometimes a barrier to seeking ANC for poor rural women. It included transport costs, opportunity costs of not being able to work in the household and service-related costs (such as blood or urine tests). The effect of cost as a barrier varied between women of different socio-economic status. Cost was a barrier to accessing ANC partly due to the womens lack of control over household resources. Social implications - – It is important to consider cost in the wider socio-economic context of rural peoples lives as financial costs alone do not explain the level of uptake of ANC. Originality/value - – This study provides an original insight of womens experiences on financial issues relating to the use of ANC services in Nepal. Another important aspect of this study was approached with the multiple respondents (i.e. women, their husbands and their mothers-in-law) regarding the use of ANC and financial impact in the use of services. The findings of this study have important implications in health policy formation by providing clear picture of womens financial situation in access to ANC.