Place, Time and Experience: Barriers to Universalization of Institutional Child Delivery in Rural Mozambique

By Agadjanian, Victor; Yao, Jing et al. | International Perspectives on Sexual and Reproductive Health, March 2016 | Go to article overview

Place, Time and Experience: Barriers to Universalization of Institutional Child Delivery in Rural Mozambique


Agadjanian, Victor, Yao, Jing, Hayford, Sarah R., International Perspectives on Sexual and Reproductive Health


CONTEXT: Although institutional coverage of childbirth is increasing in the developing world, a substantial minority of births in rural Mozambique still occur outside of health facilities. Identifying the remaining barriers to safe professional delivery services can aid in achieving universal coverage.

METHODS: Survey data collected in 2009 from 1,373 women in Gaza, Mozambique, were used in combination with spatial, meteorological and health facility data to examine patterns in place of delivery. Geographic information system-based visualization and mapping and exploratory spatial data analysis were used to outline the spatial distribution of home deliveries. Multilevel logistic regression models were constructed to identify associations between individual, spatial and other characteristics and whether women's most recent delivery took place at home.

RESULTS: Spatial analysis revealed high- and low-prevalence clusters of home births. In multivariate analyses, women with a higher number of clinics within 10 kilometers of their home had a reduced likelihood of home delivery, but those living closer to urban centers had an increased likelihood. Giving birth during the rainy, high agricultural season was positively associated with home delivery, while household wealth was negatively associated with home birth. No associations were evident for measures of exposure to and experience with health institutions.

CONCLUSIONS: The results suggest the need for a comprehensive approach to expansion of professional delivery services. Such an approach should complement measures facilitating physical access to health institutions for residents of harder-to-reach areas with community-based interventions aimed at improving rural women's living conditions and opportunities, while also taking into account seasonal and other variables.

Universal access to institutional deliveries is a critical goal of rural maternal and child health care systems in resource-limited settings. Even in countries where maternal and child health care is heavily subsidized or free and where the proportion of institutional deliveries has markedly increased in recent times, a substantial proportion of women do not deliver at health facilities, thereby jeopardizing their health and that of their babies. Previous research has identified various characteristics that are associated with the type of place where women give birth. For example, women's education level is positively associated with the likelihood of an in-facility delivery. (1-4) Similarly, women from better-off households are more likely than other women to deliver their babies at health facilities. (3-9) Cultural norms, (10) religion (8) and the influence of household and community members (11) may play important roles. Aside from the individual, household and community characteristics that may shape access to maternal and child health services, the characteristics of health care institutions and especially the quality of care that women perceive or experience are associated with women's decision to deliver at a health facility. (4,10-14)

While some women may choose not to deliver at a clinic, opting instead for the assistance of nonprofessional providers in their communities, many are unable to reach a facility in time because of distance or the cost or unavailability of transportation. (15) Indeed, spatial inequalities in access to delivery care services have been noted as a major determinant of place of delivery. (3,4,6,9,10,16-18) Finally, the physical accessibility of maternal and child health facilities may vary throughout the year depending on rainfall, though the empirical evidence is inconsistent. For example, a Zambian study found a higher likelihood of institutional deliveries during a dry season than during a rainy season, (15) whereas no association was apparent in Ghana. (18)

Most studies exploring the correlates of place of child delivery have focused on settings in which only a small share of births occur at health facilities. …

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