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

Abstract

Background: Skilled 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.

Methods: We 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.

Results: There 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.

Conclusion: Studies 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.

Figures

Figure 1

Delay phases and factors affecting use of delivery care and maternal mortality (adapted from Thaddeus & Maine). The three delays for emergency care-seeking are unchanged from the framework presented by Thaddeus and Maine. We conceptually separated preventive care-seeking. Only a first and second phase are relevant for receiving normal preventive delivery care. If a woman who is receiving such preventive care at a health facility then develops a complication, her survival will depend on whether she receives adequate and appropriate treatment in time (third delay of emergency care-seeking). Since she is already in a facility, skilled providers should be able to discover this quickly (no first emergency delay) and she does not need to travel far if it can be handled there (no second emergency delay). For those complications that cannot be handled at that facility and that require referral to a higher-level facility, she will need to travel to a referral facility, possibly with help from the first facility (second emergency delay).