Table 1 Factors thought to be associated with skilled delivery service use in the literature
From: Still too far to walk: Literature review of the determinants of delivery service use
Determinant* | Rationale | Findings |
|---|---|---|
Sociocultural factors | ||
Maternal age +++ | Older women: more experienced in using services, more confident, more say in household. Young women: more modern. | No difference, or older women more likely to use services in all multivariate studies examined. |
Marital status ++ | Single mothers more autonomous: more use. But maybe poorer and stigmatized: less use. | No association or either direction. |
Ethnicity, religion, traditional beliefs +++ | Certain cultural backgrounds, beliefs, norms and values as well as discrimination may decrease care-seeking. | Mixed results. Large differences in some studies, none in others. |
Family composition + | Small children at home and no extended family to help should decrease use. | Some found less skilled care if higher number of births in previous five years. |
Mother's education +++ | Knowledge, access to written information, modern culture, more confident, higher earnings, control over resources, better communication with husband and providers, etc. should all increase use. | Consistently strong and dose-dependent positive effect on delivery service use. |
Husband's education ++ | Knowledge, modern attitudes, better communication between spouses, higher autonomy for wife, higher earnings, etc. should increase service use. | Higher husband's education consistently increases skilled attendance; effect often smaller than effect of mother's own education. |
Women's autonomy ++ | Decision-making power, mobility, control over resources, access to transport should increase use. | Most found some aspects to increase skilled attendance, but others found no effect. |
Perceived need | ||
Information availability + | Information about risks of childbirth and about service availability in radio or TV should increase use. | Information access associated with more skilled attendance in some studies but not in others. |
Health knowledge + | Knowledge about risks of childbirth and the benefits of skilled care should increase wish to use services. | Expected association in some but not in other studies. |
Pregnancy wanted + | Higher value attached to desired child justifies expenses for skilled attendance. | Expected association in some but not in other studies. |
Perceived quality of care + | Perceived poor personal and medical quality of care, clash with culture and fear of procedures may decrease use. | Qualitative studies generally find that perceived low quality decreases use, some describe interaction with distance and cost. Very few quantitative studies. |
ANC use ++ | Familiarity with services, encouragement by health workers increases delivery service use. | Usually those attending ANC much more likely to receive skilled delivery care. |
Previous facility delivery ++ | Familiarity with services increases their use. | Nearly always very strongly associated with index facility delivery. |
Birth order +++ | First birth: more difficult, help from natal family, high value on pregnancy, or unplanned/unwanted. High order births: previous experience, confidence if no problems previously, difficulty to leave home with several small children, poorer families. | No difference or first births and lower order births more likely to have skilled attendance than high order births in the vast majority of studies examined. |
Complications + | Pregnancy complications (→ ANC advice), complications during delivery, previous complications (→ women aware, medical risk) should increase use of skilled attendance. | Qualitative studies: important factor, decreases importance of other barriers. Few quantitative studies, several found that women with complications are more likely to seek skilled care. |
Economic accessibility | ||
Mother's occupation + | Own earnings, range of movement, information should increase use. Decreased use expected if work is poverty-induced. | No effect in several studies, association in either direction. Often less use of skilled attendance among women farmers. |
Husband's occupation ++ | Higher financial resources and health insurance with some occupations should increase service use. | In several but not in all studies increased skilled attendance if higher status occupations. |
Ability to pay +++ | Costs for transport, care, opportunity costs decrease use by the poor. | Poorer women less likely to have skilled attendance, in some studies no effect. |
Physical accessibility | ||
Region, urban/rural +++ | Social and service environment differences between regions. In rural areas generally worse services and infrastructure, more poverty, more traditional beliefs, which all decrease use. | Nearly always moderate to large differentials with less service use in rural areas. |
Distance, transport, roads ++ | Distance as disincentive and actual obstacle to reach facilities, enhanced by lack of transport and poor roads. | Less service use when further away or no difference. |