Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA.
BMC Pregnancy Childbirth. 2022 Nov 2;22(1):804. doi: 10.1186/s12884-022-05111-1.
Giving birth in health facilities with skilled birth attendants (SBAs) is one of the key efforts promoted to reduce preventable maternal deaths in sub-Saharan Africa. However, research has revealed large socioeconomic status (SES) disparities in facility-based childbirth. We seek to extend the literature on the factors underlying these SES disparities. Drawing on the Disparities in Skilled Birth Attendance (DiSBA) framework, we examined the contribution of three proximal factors-perceived need, accessibility, and quality of care-that influence the use of SBAs.
We used data from a survey conducted in Migori County, Kenya in 2016, among women aged 15-49 years who gave birth nine weeks before the survey (N = 1020). The primary outcome is facility-based childbirth. The primary predictors are wealth, measured in quintiles calculated from a wealth index based on principal component analysis of household assets, and highest education level attained. Proposed mediating variables include maternal perceptions of need, accessibility (physical and financial), and quality of care (antenatal services received and experience of care). Logistic regression with mediation analysis was used to investigate the mediating effects.
Overall, 85% of women in the sample gave birth in a health facility. Women in the highest wealth quintile were more likely to give birth in a facility than women in the lowest quintile, controlling for demographic factors (adjusted odds ratio [aOR]: 2.97, 95% CI: 1.69-5.22). College-educated women were five times more likely than women with no formal education or primary education to give birth in a health facility (aOR: 4.96; 95% CI: 1.43-17.3). Women who gave birth in health facilities had higher perceived accessibility and quality of care than those who gave birth at home. The five mediators were estimated to account for between 15% and 48% of the differences in facility births between women in the lowest and higher wealth quintiles.
Our results confirm SES disparities in facility-based childbirth, with the proximal factors accounting for some of these differences. These proximal factors - particularly perceived accessibility and quality of care - warrant attention due to their relationship with facility-birth overall, and their impact on inequities in this care.
在撒哈拉以南非洲，让产妇在拥有熟练接生员的医疗机构分娩是减少可预防产妇死亡的主要努力之一。然而，研究表明，在医疗机构分娩方面存在着较大的社会经济地位（SES）差异。我们试图扩展有关导致这些 SES 差异的因素的文献。本研究借鉴了熟练接生服务差异（DiSBA）框架，探讨了影响熟练接生员使用的三个近端因素（即感知需求、可及性和护理质量）的贡献。
我们使用了 2016 年在肯尼亚米戈里县进行的一项调查数据，调查对象为在调查前 9 周分娩的 15-49 岁女性（N=1020）。主要结局是在医疗机构分娩。主要预测因素是财富，根据基于家庭资产主成分分析的财富指数，以五分位数表示，最高教育水平。提出的中介变量包括产妇对需求、可及性（身体和经济）和护理质量（接受的产前服务和护理体验）的感知。使用逻辑回归和中介分析来调查中介效应。
总体而言，样本中 85%的妇女在医疗机构分娩。与最低五分位数的妇女相比，处于最高五分位数的妇女更有可能在医疗机构分娩，控制了人口统计学因素（调整后的优势比[OR]：2.97，95%可信区间[CI]：1.69-5.22）。与没有正规教育或小学教育的妇女相比，接受过大学教育的妇女在医疗机构分娩的可能性高五倍（OR：4.96；95%CI：1.43-17.3）。在医疗机构分娩的妇女比在家分娩的妇女感知到更高的可及性和护理质量。五个中介变量估计占最低和最高五分位数妇女之间在医疗机构分娩的差异的 15%至 48%。
我们的研究结果证实了 SES 差异在医疗机构分娩方面的存在，近端因素解释了其中的一些差异。这些近端因素——特别是感知可及性和护理质量——由于与整体医疗机构分娩有关，以及对这种护理的不平等的影响，值得关注。
