14. douangphachanh xaysomphou
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  • 1. Factors influencing the decision-making regarding place of delivery among mothers in three provinces, Lao PDR
    • By
    • Douangphachanh XAYSOMPHOU, M.D. MSc
    • Faculty of Post graduate studies
    • University of Health Sciences
    • Department of Health Policy and Planning, School of International Health
    • Graduate School of Medicine, The University of Tokyo
  • 2.
    • Globally, one woman dies every minute due to pregnancy related complications, with 98% occurring in developing countries.
    • (WHO, MMR in Western Pacific Region, 2003)
    • In Lao PDR, maternal mortality ratio has been estimated to be among the highest in southeast Asia, at 660 per 100,000 live births.
    • (WHO, 2008)
    • 74% of deliveries took place at home.
    • (WHO and Lao NSC, 2006)
    • The government of Lao set up the goal; aiming at reducing maternal mortality ratio to 185 deaths per 100,000 live births by the year 2015 .
    • (Millennium Development Goals Progress report Lao PDR, 2004)
    Introduction (1)
  • 3.
    • The utilization of health care services may depend on:
      • level of education, cultural beliefs, practices, gender discrimination and economic status (Babar T et all, Pakistan, 2004 ).
      • Husbands involvement (Rafiqul L et al, 2007).
      • distance to the health care facility (K.Navaneetham et al, 2000).
    Literature review (2)
  • 4.
    • Aim : To improve quality and utilization of Health care services in Laos, which ultimately will help in maternal mortality ratio reduction and improving maternal health.
    • Objectives:
      • To determine the factors influencing the decision-making of the mothers to choose place of delivery for their last child.
    Research Aim and Objectives (3)
  • 5.
    • Selected hospitals: 3 provincial hospitals and 30 district hospitals ( n=33 ).
    • These hospital cater for 1.4 million populations representing 25% of Lao PDR population.
    Study site Selected (4) V i e n t i a n e H u a p h a n h S a v a n n a k h e t X a y a b u r y L u a n g p r a b a n P h o n g s a l y K h a m m u a n e A t t a p e u B o k e o C h a m p a s a c k X i e n g k h u a ng B o l i k h a m x a y O u d o m x a y S a r a v a n e S e k o n g L u a n g n a m t h a X a y s o m b o o n V i e n t i ane C a p i t a l
  • 6.
    • Target population:
      • Mothers with a child aged less than one year-old
    • Sample size:
      • 303 mothers, based on the prevalence 26.7% delivered at hospitals (NSC, 2006),
    • Sampling method:
      • The multistage sampling by districts and villages.
    • Inclusion criteria for mother:
      • Women who gave birth with child aged less than one year old.
      • Mothers who were willing to participate
    • Study tool:
      • Structured-questionnaire
    • Statistical issue:
      • Data analyzed using SPSS version 11.0
        • Descriptive frequency and percentage
        • Pearson’s chi-square and Logistic regression
        • P value <0.05 taken as significant
    Methodology
    • Ethics: permission from the ethical committee of the University of Tokyo in Japan and the University of Health Sciences, Ministry of Health in Lao PDR. Individual informed consents
    (5)
    • Study design: Cross-sectional study
    • Study period: January-March, 2008
  • 7. Borlikhamxay (6 Districts) Khammuane (9Districts) Savannakhet (15Districts) (1)District (63 Villages) (1)District (54 Villages) (1)District (20 Villages) 10 villages 10 villages 10 villages 303 mothers with <1 year child Systematic Random sampling Simple Random Sampling Population and housing census, 2005 (6) Community survey: Multistage probability sampling Simple Random Sampling
  • 8. Results Distance far from health facility
  • 9. Table 1: Socio-demographics and place of delivery *8,767 kip is equal to US$ 1 (8) (n=311) % Age (year) Mean (SD) 13-24 25-48 25.7 (6.1) 150 161 48.2 52.8 Ethnicity Lowland Lao (Lao Lum) Midland Lao (Lao Thung) Highland Lao (Lao Sung) 232 79 0 74.6 25.4 0.0 Household income (Kip)*/ month Mean (SD) >300,001 <300,000 1.7 (0.5) 214 97 68.8 31.2 Education of mothers Illiterate Educated 68 243 21.9 78.1 Education of fathers Illiterate Educated 50 261 16.1 83.9 Occupation of fathers Farmer Government official Daily wage worker 177 50 84 56.9 16.1 27.0 Number of children Mean (SD) ≤ 2 >2 2.6 (1.9) 190 121 61.1 38.9 Time from house go to health facility ( in minutes) by using personal transportation Mean (SD) ≤ 45 >45 44.2 (45.9) 189 113 63.7 36.6 Place of delivery Hospital Home 159 152 51.1 48.9
  • 10. Table 2: History of reproductive health and antenatal care (9) (n=311) % Parity Mean (SD) ≤ 2 >2 193 118 2.6 (2.0) 62.1 37.9 Gravida Mean (SD) ≤ 2 >2 179 132 2.8 (2.1) 57.6 42.4 Abortion Mean (SD) Never had abortion Had abortion 259 52 0.2 (0.5) 83.3 16.7 Attend antenatal clinic during the last child Yes No 207 104 66.6 33.4 Times and attended ANC during pregnancy (207) Mean (SD) ≤ 4 > 4 128 79 4.3 (1.9) 61.8 38.2 Antenatal card or booklet Yes No 148 59 71.4 28.6
  • 11. a 8,767 kip is equal to US$1 Table 3: Factors influencing place of delivery (10) Place of delivery No (%) n=311 Hospital Home OR (95% CI) P-value Ethnicity Midland Lao Lowland Lao 79 (25.4) 232 (74.6) 22 (27.8) 137 (59.1) 57 (72.2) 95 (40.9) 1 3.7 (2.1-6.5) 0.000*** Household income (Kip) a /month <300,000 >300,001 97 (31.2) 214 (68.8) 35 (36.1) 124 (57.9) 62 (63.9) 90 (42.1) 1 2.4 (1.5-4.0) 0.000*** Education of mothers No education Education 68 (21.9) 243 (78.1) 15 (22.1) 144 (59.3) 53 (77.9) 99 (40.7) 1 5.1 (2.7-9.6) 0.000*** Education of fathers No education Education 50 (16.1) 261 (83.9) 12 (24.0) 147 (56.3) 38 (76.0) 114 (43.7) 1 4.1 (2.0-8.2) 0.000*** Occupation of fathers Farmer Government official Daily wage worker 177 (56.9) 50 (16.1) 84 (27.0) 66 (37.3) 33 (66.0) 60 (71.4) 111 (62.7) 17 (34.0) 24 (28.6) 1 4.2 (2.4-7.4) 1.4 (0.6-2.7) 1 0.000*** 0.001***
  • 12. Table 4: Factors influencing place of delivery (11) Place of delivery No (%) n=311 Hospital Home OR (95%CI) p-value Gravida (times) > 2 ≤ 2 132 (42.4) 179 (57.6) 52 (39.4) 107 (59.8) 80 (60.6) 72 (40.2) 1 2.3 (1.4-3.6) 0.000*** Number of children >2 ≤ 2 121 (38.9) 190(61.1) 47 (29.6) 112 (70.4) 74 (48.7) 78 (51.3) 1 2.3 (1.4-3.6) 0.001*** Time from house go to the facility (in minute) >45 ≤ 45 113 (36.3) 198 (63.7) 36 (31.9) 123 (62.1) 77 (68.1) 75 (37.9) 1 3.5 (2.2-5.7) 0.001*** Attend ANC during the last child No Yes 104 (33.4) 207(66.6) 22 (21.2) 137 (66.2) 82 (78.8) 70 (33.8) 1 7.3 (4.2-12.7) 0.000*** Times and attend ANC during pregnancy (n=207) ≤ 4 > 4 128 (41.2) 79 (25.4) 78 (60.9) 59 (74.7) 50 (39.1) 20 (25.3) 1 1.9 (1.0-3.5) 0.043* Process an antenatal card or booklet No Yes 59 (28.5) 148 (71.4) 30 (50.8) 107 (72.3) 29 (49.2) 41 (27.7) 1 2.5 (1.4-4.7) 0.003**
  • 13. OR= Odd ratio; AOR= Adjusted odds ratio by Binary Logistic Regression (12) Table 5: Regression analysis: Factors influencing place of delivery Place of delivery No (%) n=311 Hospital Home AOR (95% CI) P-value Ethnicity Midland Lao Lowland Lao 79 (25.4) 232 (74.6) 22 (27.8) 137 (59.1) 57 (72.2) 95 (40.9) 1 1.3 (0.4-3.7) 0.632 Household income (Kip/month) <300,000 >300,001 97 (31.2) 214 (68.8) 35 (36.1) 124 (57.9) 62 (63.9) 90 (42.1) 1 1.0 (0.4-2.3) 0.952 Education of mothers No education Education 68 (21.9) 243 (78.1) 15 (22.1) 144 (59.3) 53 (77.9) 99 (40.7) 1 0.5 (0.1-1.8) 0.315 Education of fathers No education Education 50 (16.1) 261 (83.9) 12 (24.0) 147 (56.3) 38 (76.0) 114 (43.7) 1 0.9 (0.2-3.8) 0.883 Occupation of fathers Farmer Government official Daily wage worker 177 (56.9) 50 (16.1) 84 (27.0) 66 (37.3) 33 (66.0) 60 (71.4) 111 (62.7) 17 (34.0) 24 (28.6) 1 8.3 (2.9-23.5) 5.2 (1.7-16.2) 0.000*** 0.004** Gravida (times) >2 ≤ 2 132 (42.4) 179 (57.6) 52 (39.4) 107 (59.8) 80 (60.6) 72 (40.2) 1 0.5 (0.3-1.1) 0.092 Times and attended ANC (n=207) ≤ 4 >4 128 (41.2) 79 (25.4) 78 (60.9) 59 (74.7) 50 (39.1) 20 (25.3) 1 2.3 (1.1-4.8) 0.026* Process an antenatal Card or booklet No Yes 59 (28.5) 148 (71.4) 107 (72.3) 30 (50.8) 41 (27.7) 29 (49.2) 1 0.5 (0.2-1.1) 0.118 Time from home go to the facility (in minute) > 45 ≤ 45 113 (36.3) 198 (63.7) 36 (31.9) 123 (62.1) 77 (68.1) 75 (37.9) 1 2.3 (1.0-5.1) 0.042*
  • 14. Discussion
  • 15.
    • This study revealed a higher proportion of hospital delivery in the targeted villages. Half of mothers delivered their youngest child at hospital (51.1%)
      • 29% of deliveries took place at health facility (Outavong P et al. Bioscience Trends, 2008)
    • The most important factors determining hospital delivery in the study were:
      • Occupation of fathers.
        • Men play useful roles during theirs partner’s obstetric conditions to seek care (Clifford et al, 2005).
      • Timely access to hospital.
        • Less travel time to hospital (<45 minutes) is found to be associated with increase in hospital delivery.
        • Distance was barrier to the utilization of safe delivery services (Mesfin N. et al, 2004).
      • Frequency of obtaining ANC during pregnancy.
        • ANC utilization use was associated with an increase in the numbers of women who sought care at hospital (Carolyn JT et al, 2007).
    (14) Discussions
  • 16.
    • EPI coverage in Laos is not high and for this study EPI list were used to recruit mothers. There is a possibility of selection bias in the sample selection.
    • Cross sectional study design: establishing cause-effect relationship in community survey is not possible.
    (15) Limitations
  • 17.
    • Low ANC visits are associated with delivery at home and vice versa
    • Less travel time (less than 45 minutes) to facilities was also associated with hospital delivery
    • Recommendations
    • Increase in promotion of ANC utilization at community level may also increase facility delivery.
    • Provide community education to create awareness of obstetric complications, as well as maternal morbidity and mortality.
    (16) Conclusions
  • 18. Thank you