Health and Social Care in the Community (2015) 23(5), 493–501
doi: 10.1111/hsc.12165
Determinants of postnatal service utilisation among mothers in rural settings of Malawi Precious William C. Phiri
MPHM,
Cheerawit Rattanapan
PhD
and Aroonsri Mongkolchati
PhD
ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhonpathom, Thailand Accepted for publication 29 August 2014
Correspondence Cheerawit Rattanapan ASEAN Institute for Health Development Mahidol University, Salaya Phutthamonthon, Nakhonpathom 73710, Thailand E-mail: [email protected], [email protected]
What is known about this topic
• •
Predisposing and enabling factors affect use of postnatal service among mothers. Needs factors such as complications during delivery affect mothers in the utilisation of postnatal service.
What this paper adds
•
•
•
Mothers who receive health education tend to use postnatal service more compared to those who do not receive such education. Mothers who are satisfied with the performance of health workers during delivery and postnatal service are more likely to use postnatal service than those not satisfied. Mothers who use alternative local sources of care at home are less likely to use postnatal service than those who do not use such care.
Abstract The aim of this study was to determine significant predictors for the utilisation of postnatal service among mothers. A total of 295 postnatal mothers were enrolled in a cross-sectional study design undertaken in six health facilities of Lilongwe District using two-stage cluster sampling with a response rate of 100%. The data were collected by interview from December 2012 to January 2013 using a structured questionnaire. The result showed that over half of the mothers (56.6%) utilised postnatal service within 6 weeks after delivery. A stepwise multiple logistic regression was used to determine significant determinants of utilisation of postnatal service among mothers. After adjusting for confounding factors, utilisation of an alternative local source of care in home after delivery [adjusted odds ratio (aOR): 7.77, 95% CI: 4.14–14.58], women’s perception on performance of health workforce during delivery and postnatal service (aOR: 6.56, 95% CI: 3.09–13.94), health education before hospital discharge of postnatal mothers (aOR: 4.08, 95% CI: 2.11–7.92), place of delivery (aOR: 4.32, 95% CI: 1.32–14.12), family income (aOR: 1.89, 95% CI: 1.03–3.46) and the occurrence of no complications during delivery (aOR: 1.90, 95% CI: 1.03–3.50) were significantly associated with the utilisation of postnatal service. Hence, this study suggests that improved health workforce performance coupled with effective health education may increase the utilisation of postnatal service. Furthermore, the utilisation of postnatal service may also be increased through reducing home deliveries, delivery complications and the use of alternative local care at home after delivery. Integration of postnatal service in outreach clinics might also assist through reducing the cost of accessing postnatal service among mothers. Keywords: Malawi, mothers, postnatal service, rural setting, utilisation
Introduction Globally, countries are trying to reduce the burden of maternal and neonatal mortality. It is believed that maternal and neonatal mortality rates can be reduced by the utilisation of antenatal care, health facilitybased delivery and postnatal service (WHO 2011). This is because the postnatal period, the time from © 2014 John Wiley & Sons Ltd
delivery up to 6 weeks postpartum, is the most susceptible period in the reproductive life cycle of mothers (Rahman et al. 2011, WHO 2012b). Over two-thirds of neonatal deaths occur within 1 week, half of neonatal deaths occur within the first 24 hours and about six million child deaths occur in the postneonatal period annually (Titaley et al. 2009). According to the World Health Organization (WHO) 493
P. W. C. Phiri et al.
statistics, 25%–45% of neonatal mortality occurs within the first 24 hours and 70% of neonatal deaths occur in the first week following delivery (WHO 2012a). Globally, out of eight million pregnant women who suffer from pregnancy-related complications, over 50% die due to these complications (Sein 2012). Developing countries are particularly affected by high maternal and infant mortality rates (McCoy et al. 2010). In Africa, around 3.6% of children die in the first 4 weeks of life and 4.4% die within 6 weeks (WHO 2011). National statistics from Malawi indicate that around 3% of children die within the 4 weeks and 4% within the first 6 weeks. In the Lilongwe district of Malawi, the figures are around 3.3% within 4 weeks and 3.5% within 6 weeks (National Statistical Office 2010). The maternal mortality rate in developing countries is around 620 per 100,000 pregnant women (WHO 2011). In Malawi, it is 510 per 100,000 pregnant women (National Statistical Office 2010). In Lilongwe, 95.7% of pregnant women attend antenatal visits and 70.6% of deliveries are attended by skilled health personnel. However, there is low postnatal service coverage. Only 43% of women in Lilongwe attend postnatal service after delivery. This drops to 34% in rural areas (National Statistical Office 2010). Several studies (Andersen 1995, Tomlinson et al. 2011) have established that individual determinants are associated with the use of postnatal service. These determinants can be categorised into three groups: predisposing, enabling and need factors. The results showed that predisposing factors prompt mothers to use postnatal service. Among these predisposing factors are the mother’s age (Matijasevich et al. 2009, Agha & Carton 2011), the educational status of the mother and father (Sagna & Sunil 2012), the mother’s and father’s occupational status (Abor et al. 2011, Rahman et al. 2011), marital status (Matijasevich et al. 2009), birth order (Babalola & Fatuai 2009, Singh et al. 2010), exposure of women to media (Babalola & Fatuai 2009), knowledge of pregnancy complications (Rahman et al. 2011, Singh & Yadav 2012) and cultural practices (Mistray et al. 2009, Woldemicael 2010, Worldemdicael & Tenkorang 2010, Gabrysch et al. 2011, Rai et al. 2012). However, predisposing factors are facilitated by availability of enabling factors among mothers. The enabling factors, which include individual resources and community resources, support mothers to utilise postnatal service. Previous studies (WHO 2006, Singh et al. 2010, Agha 2011, Paul et al. 2011, Tayelgn et al. 2011, Tomlinson et al. 2011, Turan et al. 2011) have confirmed that individual and community resources affect the use of post494
natal service among mothers. Among these resources are family income (Bassani et al. 2009, Fan & Habibov 2009, Jat et al. 2011), health insurance (Rob et al. 2009, Agha 2011, Ahmed & Khan 2011, Nguyen et al. 2012, Obare et al. 2012), the frequency of antenatal visits (Nikiema et al. 2009, Titaley et al. 2009, De Allegri et al. 2011, Ntambue et al. 2012), distance to health facility (Liabsuetrakul & Oumudee 2011, Sein 2012) and place of delivery (Rahman et al. 2011, Ntambue et al. 2012). Lastly, mothers might not use postnatal service unless they feel a need for them. Several studies (Khalaf et al. 2009, Pembe et al. 2009, Kabalyenga et al. 2011, Rahman et al. 2011, Titaley et al. 2011, Rai et al. 2012, Sagna & Sunil 2012, Sein 2012) have shown that need factors such as occurrence of pregnancy-related complications during delivery among mothers necessitate the utilisation of postnatal service. However, previous studies (Matijasevich et al. 2009, Mistray et al. 2009, Titaley et al. 2009, 2011, Agha & Carton 2011, De Allegri et al. 2011, Liabsuetrakul & Oumudee 2011, Guilcher et al. 2012, Singh et al. 2012) have concentrated on individual determinants, not on local community care and healthcare system-related factors. Therefore, this study’s aim was to identify individual, local community care and health workforce factors affecting the utilisation of postnatal service among rural mothers in Malawi.
Methods A cross-sectional descriptive study was conducted in a rural area in Lilongwe district, Malawi. Six health facilities were included in this study, and data were collected from mothers, who came for routine immunisations in the under-five clinic from December 2012 to January 2013. The health facilities were Nkhoma Mission Hospital, Chimbalanga Health Centre, Nathenje Health Centre, Chitedze Health Centre, M’bwatalika Mission Health Centre and Ming’ongo Health Centre. Mothers who had finished the postnatal period of 6 weeks after delivery were included in this study. Those whose delivery occurred in the district, who attended the under-five clinic and agreed to take part, were included. However, mothers who had a disability, including those who were physically handicapped or deaf, were excluded from the study. The sample size was based on an allowable margin of error of 6.5% with 95% confidence and assuming 50% of mothers would utilise postnatal service within 6 weeks of delivery, as no a priori data were available. A total of 295 mothers who had a child © 2014 John Wiley & Sons Ltd
Determinants of postnatal service utilisation
aged 7–24 months and had attended an under-five clinic for immunisation were randomly selected in the study by using a two-stage cluster sampling method. First, two of four health areas were selected by using a simple random sampling technique. Then, in each of the two health areas, three of seven health facilities were selected using simple random sampling. Finally, a systematic random sampling technique was used to select around 49 mothers from each of the six selected health facilities. Around five mothers were selected on each day of the under-five clinics over a period of 10 days. Data were collected by interviewing respondents using a structured questionnaire as most mothers in the area were illiterate. The questionnaire had three parts, namely predisposing, enabling and needs variables. The questionnaire was developed by reviewing the literature and consulting a panel of research experts from Mahidol University and experts from the Ministry of Health in Malawi. It was translated into the local language, Chichewa, and then pretested by interviewing 32 postnatal mothers at an under-five clinic at one hospital not included in the study to check its acceptability, validity and reliability. The answers from the same questions in Chichewa questionnaire and English questionnaire versions were matched. The knowledge part of the questionnaire had dichotomous questions (true or false), and its reliability was estimated using the Kuder–Richardson Formula 20 (KR20). The perception part had Likert scale questions (1 = disagree, 2 = neutral, 3 = agree), and its reliability was estimated using Cronbach’s alpha. In this study, the reliability of the knowledge part was measured as KR20 = 0.73 and the reliability of the perception part was measured as Cronbach’s alpha = 0.76. After pretesting, some changes were made to the questionnaire to suit the local setting. The questionnaire was administered by a trained data collector at each of the six health facilities. The data on use of postnatal service were collected through asking questions and verified from the mother’s health passport. Similarly, data on delivery complications were collected by asking if a mother had been admitted in the health facility over 3 days after delivery with verification of dates of delivery and discharge from the mother’s health passport. The mother’s age and family income were collected as continuous variables. Ethical approval was obtained from the Mahidol University Ethical Committee (serial no. COA.NO. 2013/021.2101), and the National Health Sciences Research Committee (NHSRC) of Malawi (serial no. NHSRC# 1118). Approval was also obtained from © 2014 John Wiley & Sons Ltd
those in charge of the health facilities and verbal consent was obtained from study participants before the interview. Data analysis Data were entered in Epidata 3.0, and exported to SPSS 16.0 for analysis. Descriptive statistics were estimated according to the use of postnatal service (yes or no) and overall, in the form of medians, quartiles, minima and maxima, or numbers and percentages as appropriate. The choice of statistical tests was based on assuming a dichotomous dependent variable and categorical independent variables. Variables such as antenatal visits and distance were pre-categorised based on government standards and others were categorised based on median subdivision. First, a chi-square test was used to determine whether each independent variable was associated with the utilisation of postnatal service (dependent variable) based on a set level of significance of 0.05. Then, all significant variables from the chi-square tests were included in a multiple logistic regression analysis. Variables such as delivery complications that were theoretically important, but whose individual association with the utilisation of postnatal service was not statistically significant, were included in the multiple logistic regression model. The health centre was not included as a variable in the analysis because they have similar background factors. Mother’s age, education and parity except delivery complications were not included in the logistic regression analysis because they were insignificant in bivariate analysis. Finally, at the significance level of 0.05, a stepwise multiple logistic regression model was fitted to determine significant predictors for the utilisation of postnatal service among mothers within 6 weeks after delivery.
Results In total, 295 respondents were randomly selected and all agreed to participate in the study (100% response rate). Only one of the six health facilities had less than half (37.7%) of the participants using postnatal service (Table 1). Over half of the mothers (56.6%) utilised postnatal service within the 6 weeks after delivery (Table 2). Around half (52.2%) of the participants were at or below the median age of 23 years. The minimum age was 15 years and maximum was 45 years. Over four-fifths (84.4%) had reached primary educational level. The median family income was $167.20, with a quartile deviation of $83.30, a minimum of $27.80 and a maximum of $2222.20. 495
P. W. C. Phiri et al.
Table 1 Distribution of respondents by use of postnatal service and health facility Utilisation of postnatal service Yes n
Health facility Nathenje Health Centre Nkhoma Mission Hospital Chimbalanga Health Centre Chitedze Health Centre M’bwatalika Mission Health Centre Ming’ongo Health Centre Total
No %
n
%
Total
25 24 29 30 40
51.0 50.0 59.2 61.2 81.6
24 24 20 19 9
49.0 50.0 40.8 38.8 18.4
49 48 49 49 49
19 167
37.3 56.6
32 128
62.7 43.4
51 295
v2(df = 5) = 22.3, P < 0.001.
Table 2 Characteristics of respondents who participated in the study (n = 295) Utilisation of postnatal service Yes Characteristics
n
Marital status Single 6 Married 161 Divorced 0 Parity 1st birth order 53 2–3 birth order 71 4th birth order and above 43 Mother’s educational status Primary incomplete 18 Primary complete 117 Secondary 32 Mother’s occupation Farming 147 Business 13 Unskilled labour 5 Skilled labour 1 Technical work 1
No n
%
Total
46.2 57.3 0.0
7 120 1
53.8 42.7 100.0
13 281 1
61.6 55.9 52.4
33 56 39
38.4 44.1 47.6
86 127 82
46.2 55.7 69.6
21 93 14
53.8 44.3 30.4
39 210 46
56.3 56.5 71.4 100.0 33.3
114 10 2 0 2
43.7 43.5 28.6 0.0 66.7
261 23 7 1 3
%
As indicated in Table 3, the chi-square test showed that there was an association between the utilisation of postnatal service among mothers and the predisposing variables of frequency of exposure to radio (P = 0.013) and knowledge about neonatal and pregnancy complications (P = 0.021). Furthermore, use of postnatal service was found to be linked with the enabling variables of family income (P = 0.037), women’s perceptions about health work496
ers’ performance during delivery/postnatal service (P < 0.001) and antenatal visits (P = 0.006). In addition, the use of postnatal service among mothers was found to be related to distance from residence to health facility (P = 0.010), place of delivery (P = 0.002) and the use of alternative sources of care at home after delivery (P < 0.001). Lastly, the use of postnatal service was found to be associated with health education before hospital discharge of postnatal mothers (P < 0.001). Six of the variables included in the model were found to be significant predictors for the utilisation of postnatal service among mothers (Table 4). Four enabling variables were found to be significant. First, mothers who were satisfied with the performance of health workers during delivery or postnatal service were more likely to use postnatal service than those who were unsatisfied (OR: 6.56, P < 0.001). Second, mothers who did not use alternative sources of care at home were more likely to use postnatal service than those who used alternative sources (OR: 7.77, P < 0.001). Third, mothers who delivered at hospital were more likely to attend postnatal clinics than mothers who delivered at home (OR: 4.32, P = 0.015). Lastly, mothers with a high family income were more likely to use postnatal service than those with a low family income (OR: 1.89, P = 0.039). In addition, both needs variables were also significant. First, mothers who received health education before hospital discharge after delivery were more likely to use postnatal service than those who did not receive health education (OR: 4.08, P < 0.001). Mothers who had no delivery complications were also more likely to use postnatal service than mothers who had delivery complications (OR: 1.90, P = 0.040).
Discussion A cross-sectional study design conducted in a rural area in Lilongwe, Malawi, aimed at determining significant predictors for the utilisation of postnatal service among mothers within 6 weeks after delivery. Our findings support the claim in the literature (Titaley et al. 2009, WHO 2009, 2012a, McCoy et al. 2010, National Statistical Office 2010, Huang et al. 2012) that there is a low utilisation rate of postnatal service among mothers within 6 weeks after delivery. The findings of this study show that the rate of utilisation of postnatal service among mothers was low (56.6%) because the Ministry of Health (MoH) recommends that all women should utilise postnatal service within 6 weeks of delivery (National Statistical Office 2010). The current findings are consistent with results of the 2010 Malawi Demographic and Health Survey © 2014 John Wiley & Sons Ltd
Determinants of postnatal service utilisation
Table 3 Association between postnatal service utilisation and socio-demographic factors (n = 295) Postnatal service utilisation 95% CI n
Yes (%)
Predisposing variables Frequency of exposure to radio None 130 48.5 1–7 days per week 165 63.0 Knowledge of newborn/pregnancy complications Low 60 43.3 High 235 60.0 Enabling variables Family income (US$) Low 164 51.2 High 131 63.4 Health workforce’s performance during delivery and postnatal service Not satisfied 67 20.9 Satisfied 228 67.1 Frequency of antenatal visits 5 km 109 46.8 ≤5 km 186 62.4 Place of delivery 295 Home 24 25.0 Hospital 271 59.4 Use of alternative local source of care after delivery 295 Yes 126 31.7 No 169 75.1 Needs variables Health education before postnatal mothers’ discharge 295 Not received 88 36.4 Received 207 65.2 Complications during delivery 295 Yes 101 48.5 No 194 40.7
P-value
No (%)
Crude OR
51.5 37.0
1 1.81
1.14–2.89
0.013*
56.7 40.0
1 1.96
1.11–3.48
0.021*
48.8 36.6
1 1.65
1.03–2.63
0.037*
79.1 32.9
1 7.72
4.03–14.80
doi: 10.1111/hsc.12165
Determinants of postnatal service utilisation among mothers in rural settings of Malawi Precious William C. Phiri
MPHM,
Cheerawit Rattanapan
PhD
and Aroonsri Mongkolchati
PhD
ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhonpathom, Thailand Accepted for publication 29 August 2014
Correspondence Cheerawit Rattanapan ASEAN Institute for Health Development Mahidol University, Salaya Phutthamonthon, Nakhonpathom 73710, Thailand E-mail: [email protected], [email protected]
What is known about this topic
• •
Predisposing and enabling factors affect use of postnatal service among mothers. Needs factors such as complications during delivery affect mothers in the utilisation of postnatal service.
What this paper adds
•
•
•
Mothers who receive health education tend to use postnatal service more compared to those who do not receive such education. Mothers who are satisfied with the performance of health workers during delivery and postnatal service are more likely to use postnatal service than those not satisfied. Mothers who use alternative local sources of care at home are less likely to use postnatal service than those who do not use such care.
Abstract The aim of this study was to determine significant predictors for the utilisation of postnatal service among mothers. A total of 295 postnatal mothers were enrolled in a cross-sectional study design undertaken in six health facilities of Lilongwe District using two-stage cluster sampling with a response rate of 100%. The data were collected by interview from December 2012 to January 2013 using a structured questionnaire. The result showed that over half of the mothers (56.6%) utilised postnatal service within 6 weeks after delivery. A stepwise multiple logistic regression was used to determine significant determinants of utilisation of postnatal service among mothers. After adjusting for confounding factors, utilisation of an alternative local source of care in home after delivery [adjusted odds ratio (aOR): 7.77, 95% CI: 4.14–14.58], women’s perception on performance of health workforce during delivery and postnatal service (aOR: 6.56, 95% CI: 3.09–13.94), health education before hospital discharge of postnatal mothers (aOR: 4.08, 95% CI: 2.11–7.92), place of delivery (aOR: 4.32, 95% CI: 1.32–14.12), family income (aOR: 1.89, 95% CI: 1.03–3.46) and the occurrence of no complications during delivery (aOR: 1.90, 95% CI: 1.03–3.50) were significantly associated with the utilisation of postnatal service. Hence, this study suggests that improved health workforce performance coupled with effective health education may increase the utilisation of postnatal service. Furthermore, the utilisation of postnatal service may also be increased through reducing home deliveries, delivery complications and the use of alternative local care at home after delivery. Integration of postnatal service in outreach clinics might also assist through reducing the cost of accessing postnatal service among mothers. Keywords: Malawi, mothers, postnatal service, rural setting, utilisation
Introduction Globally, countries are trying to reduce the burden of maternal and neonatal mortality. It is believed that maternal and neonatal mortality rates can be reduced by the utilisation of antenatal care, health facilitybased delivery and postnatal service (WHO 2011). This is because the postnatal period, the time from © 2014 John Wiley & Sons Ltd
delivery up to 6 weeks postpartum, is the most susceptible period in the reproductive life cycle of mothers (Rahman et al. 2011, WHO 2012b). Over two-thirds of neonatal deaths occur within 1 week, half of neonatal deaths occur within the first 24 hours and about six million child deaths occur in the postneonatal period annually (Titaley et al. 2009). According to the World Health Organization (WHO) 493
P. W. C. Phiri et al.
statistics, 25%–45% of neonatal mortality occurs within the first 24 hours and 70% of neonatal deaths occur in the first week following delivery (WHO 2012a). Globally, out of eight million pregnant women who suffer from pregnancy-related complications, over 50% die due to these complications (Sein 2012). Developing countries are particularly affected by high maternal and infant mortality rates (McCoy et al. 2010). In Africa, around 3.6% of children die in the first 4 weeks of life and 4.4% die within 6 weeks (WHO 2011). National statistics from Malawi indicate that around 3% of children die within the 4 weeks and 4% within the first 6 weeks. In the Lilongwe district of Malawi, the figures are around 3.3% within 4 weeks and 3.5% within 6 weeks (National Statistical Office 2010). The maternal mortality rate in developing countries is around 620 per 100,000 pregnant women (WHO 2011). In Malawi, it is 510 per 100,000 pregnant women (National Statistical Office 2010). In Lilongwe, 95.7% of pregnant women attend antenatal visits and 70.6% of deliveries are attended by skilled health personnel. However, there is low postnatal service coverage. Only 43% of women in Lilongwe attend postnatal service after delivery. This drops to 34% in rural areas (National Statistical Office 2010). Several studies (Andersen 1995, Tomlinson et al. 2011) have established that individual determinants are associated with the use of postnatal service. These determinants can be categorised into three groups: predisposing, enabling and need factors. The results showed that predisposing factors prompt mothers to use postnatal service. Among these predisposing factors are the mother’s age (Matijasevich et al. 2009, Agha & Carton 2011), the educational status of the mother and father (Sagna & Sunil 2012), the mother’s and father’s occupational status (Abor et al. 2011, Rahman et al. 2011), marital status (Matijasevich et al. 2009), birth order (Babalola & Fatuai 2009, Singh et al. 2010), exposure of women to media (Babalola & Fatuai 2009), knowledge of pregnancy complications (Rahman et al. 2011, Singh & Yadav 2012) and cultural practices (Mistray et al. 2009, Woldemicael 2010, Worldemdicael & Tenkorang 2010, Gabrysch et al. 2011, Rai et al. 2012). However, predisposing factors are facilitated by availability of enabling factors among mothers. The enabling factors, which include individual resources and community resources, support mothers to utilise postnatal service. Previous studies (WHO 2006, Singh et al. 2010, Agha 2011, Paul et al. 2011, Tayelgn et al. 2011, Tomlinson et al. 2011, Turan et al. 2011) have confirmed that individual and community resources affect the use of post494
natal service among mothers. Among these resources are family income (Bassani et al. 2009, Fan & Habibov 2009, Jat et al. 2011), health insurance (Rob et al. 2009, Agha 2011, Ahmed & Khan 2011, Nguyen et al. 2012, Obare et al. 2012), the frequency of antenatal visits (Nikiema et al. 2009, Titaley et al. 2009, De Allegri et al. 2011, Ntambue et al. 2012), distance to health facility (Liabsuetrakul & Oumudee 2011, Sein 2012) and place of delivery (Rahman et al. 2011, Ntambue et al. 2012). Lastly, mothers might not use postnatal service unless they feel a need for them. Several studies (Khalaf et al. 2009, Pembe et al. 2009, Kabalyenga et al. 2011, Rahman et al. 2011, Titaley et al. 2011, Rai et al. 2012, Sagna & Sunil 2012, Sein 2012) have shown that need factors such as occurrence of pregnancy-related complications during delivery among mothers necessitate the utilisation of postnatal service. However, previous studies (Matijasevich et al. 2009, Mistray et al. 2009, Titaley et al. 2009, 2011, Agha & Carton 2011, De Allegri et al. 2011, Liabsuetrakul & Oumudee 2011, Guilcher et al. 2012, Singh et al. 2012) have concentrated on individual determinants, not on local community care and healthcare system-related factors. Therefore, this study’s aim was to identify individual, local community care and health workforce factors affecting the utilisation of postnatal service among rural mothers in Malawi.
Methods A cross-sectional descriptive study was conducted in a rural area in Lilongwe district, Malawi. Six health facilities were included in this study, and data were collected from mothers, who came for routine immunisations in the under-five clinic from December 2012 to January 2013. The health facilities were Nkhoma Mission Hospital, Chimbalanga Health Centre, Nathenje Health Centre, Chitedze Health Centre, M’bwatalika Mission Health Centre and Ming’ongo Health Centre. Mothers who had finished the postnatal period of 6 weeks after delivery were included in this study. Those whose delivery occurred in the district, who attended the under-five clinic and agreed to take part, were included. However, mothers who had a disability, including those who were physically handicapped or deaf, were excluded from the study. The sample size was based on an allowable margin of error of 6.5% with 95% confidence and assuming 50% of mothers would utilise postnatal service within 6 weeks of delivery, as no a priori data were available. A total of 295 mothers who had a child © 2014 John Wiley & Sons Ltd
Determinants of postnatal service utilisation
aged 7–24 months and had attended an under-five clinic for immunisation were randomly selected in the study by using a two-stage cluster sampling method. First, two of four health areas were selected by using a simple random sampling technique. Then, in each of the two health areas, three of seven health facilities were selected using simple random sampling. Finally, a systematic random sampling technique was used to select around 49 mothers from each of the six selected health facilities. Around five mothers were selected on each day of the under-five clinics over a period of 10 days. Data were collected by interviewing respondents using a structured questionnaire as most mothers in the area were illiterate. The questionnaire had three parts, namely predisposing, enabling and needs variables. The questionnaire was developed by reviewing the literature and consulting a panel of research experts from Mahidol University and experts from the Ministry of Health in Malawi. It was translated into the local language, Chichewa, and then pretested by interviewing 32 postnatal mothers at an under-five clinic at one hospital not included in the study to check its acceptability, validity and reliability. The answers from the same questions in Chichewa questionnaire and English questionnaire versions were matched. The knowledge part of the questionnaire had dichotomous questions (true or false), and its reliability was estimated using the Kuder–Richardson Formula 20 (KR20). The perception part had Likert scale questions (1 = disagree, 2 = neutral, 3 = agree), and its reliability was estimated using Cronbach’s alpha. In this study, the reliability of the knowledge part was measured as KR20 = 0.73 and the reliability of the perception part was measured as Cronbach’s alpha = 0.76. After pretesting, some changes were made to the questionnaire to suit the local setting. The questionnaire was administered by a trained data collector at each of the six health facilities. The data on use of postnatal service were collected through asking questions and verified from the mother’s health passport. Similarly, data on delivery complications were collected by asking if a mother had been admitted in the health facility over 3 days after delivery with verification of dates of delivery and discharge from the mother’s health passport. The mother’s age and family income were collected as continuous variables. Ethical approval was obtained from the Mahidol University Ethical Committee (serial no. COA.NO. 2013/021.2101), and the National Health Sciences Research Committee (NHSRC) of Malawi (serial no. NHSRC# 1118). Approval was also obtained from © 2014 John Wiley & Sons Ltd
those in charge of the health facilities and verbal consent was obtained from study participants before the interview. Data analysis Data were entered in Epidata 3.0, and exported to SPSS 16.0 for analysis. Descriptive statistics were estimated according to the use of postnatal service (yes or no) and overall, in the form of medians, quartiles, minima and maxima, or numbers and percentages as appropriate. The choice of statistical tests was based on assuming a dichotomous dependent variable and categorical independent variables. Variables such as antenatal visits and distance were pre-categorised based on government standards and others were categorised based on median subdivision. First, a chi-square test was used to determine whether each independent variable was associated with the utilisation of postnatal service (dependent variable) based on a set level of significance of 0.05. Then, all significant variables from the chi-square tests were included in a multiple logistic regression analysis. Variables such as delivery complications that were theoretically important, but whose individual association with the utilisation of postnatal service was not statistically significant, were included in the multiple logistic regression model. The health centre was not included as a variable in the analysis because they have similar background factors. Mother’s age, education and parity except delivery complications were not included in the logistic regression analysis because they were insignificant in bivariate analysis. Finally, at the significance level of 0.05, a stepwise multiple logistic regression model was fitted to determine significant predictors for the utilisation of postnatal service among mothers within 6 weeks after delivery.
Results In total, 295 respondents were randomly selected and all agreed to participate in the study (100% response rate). Only one of the six health facilities had less than half (37.7%) of the participants using postnatal service (Table 1). Over half of the mothers (56.6%) utilised postnatal service within the 6 weeks after delivery (Table 2). Around half (52.2%) of the participants were at or below the median age of 23 years. The minimum age was 15 years and maximum was 45 years. Over four-fifths (84.4%) had reached primary educational level. The median family income was $167.20, with a quartile deviation of $83.30, a minimum of $27.80 and a maximum of $2222.20. 495
P. W. C. Phiri et al.
Table 1 Distribution of respondents by use of postnatal service and health facility Utilisation of postnatal service Yes n
Health facility Nathenje Health Centre Nkhoma Mission Hospital Chimbalanga Health Centre Chitedze Health Centre M’bwatalika Mission Health Centre Ming’ongo Health Centre Total
No %
n
%
Total
25 24 29 30 40
51.0 50.0 59.2 61.2 81.6
24 24 20 19 9
49.0 50.0 40.8 38.8 18.4
49 48 49 49 49
19 167
37.3 56.6
32 128
62.7 43.4
51 295
v2(df = 5) = 22.3, P < 0.001.
Table 2 Characteristics of respondents who participated in the study (n = 295) Utilisation of postnatal service Yes Characteristics
n
Marital status Single 6 Married 161 Divorced 0 Parity 1st birth order 53 2–3 birth order 71 4th birth order and above 43 Mother’s educational status Primary incomplete 18 Primary complete 117 Secondary 32 Mother’s occupation Farming 147 Business 13 Unskilled labour 5 Skilled labour 1 Technical work 1
No n
%
Total
46.2 57.3 0.0
7 120 1
53.8 42.7 100.0
13 281 1
61.6 55.9 52.4
33 56 39
38.4 44.1 47.6
86 127 82
46.2 55.7 69.6
21 93 14
53.8 44.3 30.4
39 210 46
56.3 56.5 71.4 100.0 33.3
114 10 2 0 2
43.7 43.5 28.6 0.0 66.7
261 23 7 1 3
%
As indicated in Table 3, the chi-square test showed that there was an association between the utilisation of postnatal service among mothers and the predisposing variables of frequency of exposure to radio (P = 0.013) and knowledge about neonatal and pregnancy complications (P = 0.021). Furthermore, use of postnatal service was found to be linked with the enabling variables of family income (P = 0.037), women’s perceptions about health work496
ers’ performance during delivery/postnatal service (P < 0.001) and antenatal visits (P = 0.006). In addition, the use of postnatal service among mothers was found to be related to distance from residence to health facility (P = 0.010), place of delivery (P = 0.002) and the use of alternative sources of care at home after delivery (P < 0.001). Lastly, the use of postnatal service was found to be associated with health education before hospital discharge of postnatal mothers (P < 0.001). Six of the variables included in the model were found to be significant predictors for the utilisation of postnatal service among mothers (Table 4). Four enabling variables were found to be significant. First, mothers who were satisfied with the performance of health workers during delivery or postnatal service were more likely to use postnatal service than those who were unsatisfied (OR: 6.56, P < 0.001). Second, mothers who did not use alternative sources of care at home were more likely to use postnatal service than those who used alternative sources (OR: 7.77, P < 0.001). Third, mothers who delivered at hospital were more likely to attend postnatal clinics than mothers who delivered at home (OR: 4.32, P = 0.015). Lastly, mothers with a high family income were more likely to use postnatal service than those with a low family income (OR: 1.89, P = 0.039). In addition, both needs variables were also significant. First, mothers who received health education before hospital discharge after delivery were more likely to use postnatal service than those who did not receive health education (OR: 4.08, P < 0.001). Mothers who had no delivery complications were also more likely to use postnatal service than mothers who had delivery complications (OR: 1.90, P = 0.040).
Discussion A cross-sectional study design conducted in a rural area in Lilongwe, Malawi, aimed at determining significant predictors for the utilisation of postnatal service among mothers within 6 weeks after delivery. Our findings support the claim in the literature (Titaley et al. 2009, WHO 2009, 2012a, McCoy et al. 2010, National Statistical Office 2010, Huang et al. 2012) that there is a low utilisation rate of postnatal service among mothers within 6 weeks after delivery. The findings of this study show that the rate of utilisation of postnatal service among mothers was low (56.6%) because the Ministry of Health (MoH) recommends that all women should utilise postnatal service within 6 weeks of delivery (National Statistical Office 2010). The current findings are consistent with results of the 2010 Malawi Demographic and Health Survey © 2014 John Wiley & Sons Ltd
Determinants of postnatal service utilisation
Table 3 Association between postnatal service utilisation and socio-demographic factors (n = 295) Postnatal service utilisation 95% CI n
Yes (%)
Predisposing variables Frequency of exposure to radio None 130 48.5 1–7 days per week 165 63.0 Knowledge of newborn/pregnancy complications Low 60 43.3 High 235 60.0 Enabling variables Family income (US$) Low 164 51.2 High 131 63.4 Health workforce’s performance during delivery and postnatal service Not satisfied 67 20.9 Satisfied 228 67.1 Frequency of antenatal visits 5 km 109 46.8 ≤5 km 186 62.4 Place of delivery 295 Home 24 25.0 Hospital 271 59.4 Use of alternative local source of care after delivery 295 Yes 126 31.7 No 169 75.1 Needs variables Health education before postnatal mothers’ discharge 295 Not received 88 36.4 Received 207 65.2 Complications during delivery 295 Yes 101 48.5 No 194 40.7
P-value
No (%)
Crude OR
51.5 37.0
1 1.81
1.14–2.89
0.013*
56.7 40.0
1 1.96
1.11–3.48
0.021*
48.8 36.6
1 1.65
1.03–2.63
0.037*
79.1 32.9
1 7.72
4.03–14.80
