RESEARCH ARTICLE Open AccessQuality of antenatal care pred.docx

RESEARCH ARTICLE Open Access
Quality of antenatal care predicts retention
in skilled birth attendance: a multilevel
analysis of 28 African countries
Adanna Chukwuma1,2* , Adaeze C. Wosu3, Chinyere Mbachu4
and Kelechi Weze1
Abstract
Background: An effective continuum of maternal care ensures
that mothers receive essential health packages from
pre-pregnancy to delivery, and postnatally, reducing the risk of
maternal death. However, across Africa, coverage of
skilled birth attendance is lower than coverage for antenatal
care, indicating mothers are not retained in the
continuum between antenatal care and delivery. This paper
explores predictors of retention of antenatal care
clients in skilled birth attendance across Africa, including
sociodemographic factors and quality of antenatal care
received.
Methods: We pooled nationally representative data from
Demographic and Health Surveys conducted in 28 African
countries between 2006 and 2015. For the 115,374 births in our
sample, we estimated logistic multilevel models of
retention in skilled birth attendance (SBA) among clients that
received skilled antenatal care (ANC).
Results: Among ANC clients in the study sample, 66% received
SBA. Adjusting for all demographic covariates and
country indicators, the odds of retention in SBA were higher

among ANC clients that had their blood pressure
checked, received information about pregnancy complications,
had blood tests conducted, received at least one
tetanus injection, and had urine tests conducted.
Conclusions: Higher quality of ANC predicts retention in SBA
in Africa. Improving quality of skilled care received
prenatally may increase client retention during delivery,
reducing maternal mortality.
Keywords: Antenatal, Continuum, Delivery, Birth, Quality,
Determinants, Maternal health
Background
Sub-Saharan Africa has the highest regional maternal
mortality ratio in the world with 546 maternal deaths
per 10,000 live births [1]. The risk of maternal death
peaks around the time of birth, when coverage of care is
at its lowest [2]. An effective continuum of skilled ma-
ternal care ensures that mothers receive essential health
packages from pre-pregnancy to delivery, and postna-
tally, reducing the risk of maternal death [2]. However,
across Africa, the proportion of mothers that receive
skilled birth attendance (51%) is lower than the propor-
tion that receives any skilled antenatal care (78%) [3].
Where this difference is due to dropouts from skilled
delivery care represents missed opportunities to reduce
maternal mortality in Africa.
Understanding predictors of retention in the con-
tinuum of care can inform policy and programs to re-
duce maternal mortality. To date, few studies have
characterized the determinants of retention along the
continuum of care in Africa. These include a recent
study of 6 countries (Ethiopia, Malawi, Rwanda, Senegal,

Tanzania, and Uganda) [4] and another study that fo-
cused on Nigeria [5]. These studies focused exclusively
on demographic characteristics of antenatal clients,
demonstrating that retention in subsequent skilled birth
attendance is predicted by factors such as higher wealth
and maternal education. There is however little evidence
on the influence of prior antenatal care experience on
subsequent retention in the continuum of maternal care,
* Correspondence: [email protected]
1Harvard T.H. Chan School of Public Health, 677 Huntington
Avenue, Boston,
MA 02115, USA
2World Bank Group, 1818 H St. NW, Washington, DC 20433,
USA
Full list of author information is available at the end of the
article
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the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
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the data made available in this article, unless otherwise stated.
Chukwuma et al. BMC Pregnancy and Childbirth (2017) 17:152
DOI 10.1186/s12884-017-1337-1
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independent of demographic determinants of maternal
health care use.
This paper contributes to the evidence base on re-
tention along the continuum of maternal care in
Africa in two definite ways. Firstly, we explore the as-
sociation between retention in care and the experi-
ence of prior care received along the continuum,
adjusting for demographic determinants of care use,
in a multilevel analysis. We assess antenatal care ex-
periences relative to the focused antenatal care model
developed by the World Health Organization and in-
formed by a multi-country randomized controlled
trial. The focused antenatal care model involves the
delivery of evidence-based essential interventions over
four visits in uncomplicated pregnancies or more
visits otherwise [2]. Secondly, we expand analysis of
determinants of retention in the continuum of care to
28 African countries for which data is available in the
Demographic and Health Surveys (DHS) database.
The results of this paper will inform facility-level ef-
forts to increase retention in care and reduce
preventable maternal mortality in Africa.
Methods
Study Sample
The study sample was drawn from the births recode
data files of the latest Standard DHS conducted in each
sub-Saharan African country between 2000 and 2016,
where the full complement of variables for the study
was collected. The DHS samples were based on a strati-

fied two-stage cluster design. In the first stage, clusters
are drawn from census files. In the second stage, a sam-
ple of households is drawn from each selected cluster.
The birth recode data files of the nationally representa-
tive Demographic and Health Surveys include the full
birth histories over the 3–5 preceding years of women
in these households including information on preg-
nancy, postnatal care, immunization, and child health.
The final sample covers surveys from 28 countries
with unrestricted data access and that include the full
complement of variables explored in the study. This
sample represents a population of 740 million or 70% of
the total population in sub-Saharan Africa in 2015. The
following surveys were included: Benin, 2011–2012; Bur-
kina Faso, 2010; Burundi, 2010; Cameroon, 2011; Chad,
2014–2015; Comoros, 2012; Congo, 2011–2012; Demo-
cratic Republic of Congo/DRC, 2013–2014; Ethiopia,
2011; Gabon, 2012; Gambia, 2013; Ghana, 2014; Ivory
Coast, 2011–2012; Kenya, 2014; Lesotho, 2014; Liberia,
2013; Madagascar, 2008–2009; Malawi, 2010; Mali,
2012–2013; Mozambique, 2011; Namibia, 2013; Niger,
2012; Nigeria, 2013; Sierra Leone, 2013; Swaziland,
2006–2007; Tanzania, 2010; Togo, 2013–2014; Zambia,
2013–2014; and Zimbabwe, 2010–2011.
Study Variables
The dependent variable in this study is retention in
skilled birth attendance (SBA) among skilled antenatal
care (ANC) clients. This variable is coded as ‘1’ if the re-
spondent received any ANC (that is attended ANC at
least once) and SBA in the index pregnancy, and ‘0’ if
the respondent did not receive SBA, but had received
any ANC in the index pregnancy. We defined skilled
care as care provided by a doctor, nurse, or midwife, in
line with the World Health Organization policy guide-

lines, as several countries did not have standardized defi-
nitions for skilled maternal care providers [6].
To fit a model of retention in SBA for ANC clients, we
drew on the framework for health care access by Pench-
ansky and Thomas [7]. The framework captures demand
and supply-side determinants of care access along five
dimensions (availability, accessibility, accommodation,
affordability, and acceptability). We conducted a review of
the literature on factors demonstrated to be associated
with the use of maternal health care [8], [9]. We then
included covariates, collected consistently across the 28
countries that represented at least one dimension of
access within the framework.
The availability dimension refers to the adequacy of
the supply of skilled health workers, facilities, and ser-
vices, and provides information on the quality of care re-
ceived during ANC, where good quality of care
corresponds to the recommended model by the World
Health Organization of focused ANC based on at least
four goal-oriented-visits [2]. We included indicators for
the following variables: location of care in the facility,
the conduct of any urine test, the conduct of any blood test,
having had a blood pressure check, receiving at least one
tetanus injection, attending up to 4 visits, and receiving any
information on potential pregnancy complications.
The accessibility dimension accounts for client trans-
portation resources, distance and travel time to care. We
thus included an indicator for living in an urban area, as
poor physical access to social services correlates with
rural dwelling across Africa [10]. Under the affordability
dimension, that is the ability to pay and financial protec-
tion during care-seeking, we included indicators for hav-
ing health insurance, possessing any primary education

or higher, having a partner who has any primary educa-
tion or higher and belonging to the richest two wealth
quintiles.
The acceptability dimension refers to the influences of
personal characteristics of the provider and client on
care-seeking. We thus included indicators for parity
(primiparous for the first birth and grand multiparous
for more than five previous births, so that women with 1
to 4 previous births were considered the reference cat-
egory). We also included indicators for women’s age.
Women below 18 years and those above 35 years were
Page 2 of 10
collapsed into one category and considered as the refer-
ence category (compared with women between 18 and
35 years old), as young and older maternal age has been
shown to influence both maternal decisions to initiate
care-seeking and the interaction with health care pro-
viders during pregnancy [11]. We also included an indi-
cator variable for each country included in the study as
a proxy for the national context.
Statistical Analysis
For each included country, we calculated the mean levels
of ANC, SBA, and the gap in coverage between ANC
and SBA (calculated as the difference between mean
ANC and mean SBA levels). For the observations with
the complete set of covariates (the analytic sample), we
estimated the means and standard errors for the study
dependent and independent variables, weighted based
on client sampling weights. On the analytic sample, we

then estimated a two-level logistic regression model of
SBA retention, nesting each birth (individual-level)
within a cluster. As several mothers reported only one
birth over the survey period, we did not construct a
three-level model that included random effects at the
maternal level. The empirical model included random
intercepts for the cluster, fixed effects for each country,
and was weighted using respondent sample weights to
ensure representativeness at the national level. We cate-
gorized the covariates into three blocks: country indica-
tors (binary variables indicating the country in which the
survey was conducted), ANC characteristics (corre-
sponding to the availability dimension of the access to
care framework) and demographic characteristics. We
progressively added these blocks of covariates into the
empirical model and computed the intraclass correlation
(ICC), that is the DHS cluster-level correlation, to
estimate the extent to which the individual probability of
retention in SBA for ANC clients in the same DHS clus-
ter was similar compared to individuals from other DHS
clusters. The ICC expresses the proportion of the total
variance that is at the DHS cluster level. We estimated
the ICC using the latent variable method [12] as follows:
ICC ¼ VarDHS Cluster
VarDHS Cluster þ π2 3=
Where VarDHS Cluster is the variance between DHS
clusters and π2 3= is the variance between individuals.
We then estimated the proportion of the cluster-level
variance that is explained by different blocks of covari-
ates as follows:
Varexplained ¼
Var0−Var1

Var0
Where Var0 is the variance in the initial or empty
model, and Var1 is the second-level variance in the
models with various blocks of covariates. For each covar-
iate, we reported the odds ratio (OR) and 95% confi-
dence interval (CI). As Benin had the highest percentage
of ANC clients retained in SBA in the fully-adjusted
models, we considered this the reference category in our
multilevel models. All analyses were conducted using
STATA 14.2.
Results
The pooled sample from 28 countries included 242,550
births with information on ANC and SBA coverage. On
average, 75% of mothers received ANC, with a standard
deviation of 20%. A total of 18 out of the 28 countries in
the study sample had attained ANC coverage levels at or
above 80% (Fig. 1). On the other hand, 53% of mothers
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Country
skilled antenatal care 80 % coverage
Fig. 1 Percentage of pregnant mothers receiving skilled
antenatal care (ANC) in 28 African countries. Notes – DRC:
Democratic Republic
of Congo
Page 3 of 10
received SBA, with a standard deviation of 20%. Only 5
out of the 28 countries in the study sample had attained
coverage levels at or above 80% (Fig. 2). The percentage of
mothers that received ANC exceeded the corresponding
percentage for SBA by 22 percentage points on average,
with a standard deviation of 14 percentage points. This
gap in coverage was as high as 46 percentage points in
Mozambique. In one country (Zimbabwe), the proportion
of mothers receiving SBA exceeded ANC (Fig. 3).
Subsequent analysis is restricted to the 115,374 births
(48%) that also had complete data on the included co-

variates, forming our analytic sample (Table 1).
In the analytic sample, 7% had health insurance, 39%
lived in an urban area and 81% were aged between 18
and 35 years. While 87% of clients reported having their
blood pressure checked at least once during ANC for
the index pregnancy, 39% received no information about
pregnancy complications during their visit with a skilled
provider in ANC (Table 2). The probability of retaining
ANC clients in SBA was 66%.
In Table 3, we present the results of the multilevel lo-
gistic regression models of retention of ANC clients in
SBA that adjust for all the study covariates. In the fully-
adjusted models, the odds of retention in SBA were
higher among ANC clients that had health insurance
(OR = 1.79, 95% CI = 1.57–2.04); who lived in urban
areas (OR = 3.31, 95% CI = 3.08–3.56); who belonged to
the richest two quintiles (OR = 1.89, 95% CI = 1.78–
2.02); that had at least primary education (OR = 1.44,
95% CI = 1.36–1.53) and had partners with at least pri-
mary education (OR = 1.37, 95% CI = 1.30–1.45); and
who were primiparous (OR = 1.66, 95% CI = 1.56–1.77).
The odds of retention in SBA were lower among ANC
clients aged between 18–35 years (OR = 0.94, 95% CI =
0.89–0.99) and who were grand multiparous (OR = 0.84,
95% CI = 0.80–0.89).
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skilled birth attendance 80 % coverage
Fig. 2 Percentage of pregnant mothers receiving skilled birth
attendance (SBA) in 28 African countries. Notes – DRC:
Democratic Republic of Congo
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Fig. 3 Difference in percentage of pregnant mothers receiving
ANC and SBA in 28 African countries. Notes – DRC:
Democratic Republic of Congo
Page 4 of 10
Adjusting for demographic covariates and country in-
dicators, receiving recommended services during ANC
consultations increased the odds of retention in SBA.
The odds of retention in SBA were higher among ANC
clients that had their blood pressure checked (OR =
1.18, 95% CI = 1.10–1.27), received information about
pregnancy complications (OR = 1.18, 95% CI = 1.12–

1.24), had blood tests conducted (OR = 1.31, 95% CI =
1.22–1.40), received at least one tetanus injection (OR
= 1.12, 95% CI = 1.06–1.19), and had urine tests con-
ducted (OR = 1.55, 95% CI = 1.46–1.65). Retention in
SBA was also higher among mothers who attended at
least 4 ANC visits (OR = 1.57, 95% CI = 1.51–1.65) but
was lower if the client received care in a health facility
(OR = 0.88, 95% CI = 0.82–0.96). Compared to Benin
(the reference category), the odds of retention in SBA
among ANC clients was lower in every country within
the study sample, when the full set of study covariates
were adjusted for.
We also estimate the cluster-level variance explained
by each block of covariates. Country-level indicators ex-
plain 35.9% of the cluster-level variance. The addition of
demographic characteristics increased variance explained
to 63.9% of the cluster-level variance that is by 28 per-
centage points. The addition of both demographic and
ANC characteristics subsequently increased cluster-level
variance explained to 65.9%t. In the fully-adjusted
models, the proportion of the variance attributable to
differences between clusters is 28.4%, indicating that
over 70% of the variance in SBA retention among ANC
clients is explained by differences between individuals in
the sample. An additional spreadsheet file shows this in
more detail (Table 4).
Discussion
In this analysis of 115,374 births in 28 African countries,
we found that one-third of ANC clients dropped out of
the maternal continuum of care prior to receiving SBA.
In consonance with the current literature, retention in
SBA among ANC clients was strongly associated with
having insurance, living in an urban area, higher wealth,

and higher education [5, 8]. In this study, primiparous
ANC clients were more likely to be retained in SBA,
while grand multiparous clients were less likely to be
retained in SBA, than clients with between one and four
previous births. This may reflect the tendency for
mothers with sufficient past delivery experience to con-
sider skilled care during pregnancy to be less salient.
However, as the risk of mortality increases among grand
multiparous mothers [13], lower levels of retention of
these ANC clients in SBA is particularly problematic.
Thus, further research exploring reasons for dropout of
grand multiparous mothers from care, and testing inter-
ventions to increase their retention is needed.
A prior systematic review showed a positive correl-
ation between ANC attendance and health facility deliv-
ery, and the authors hypothesized that this correlation
may reflect receipt of good quality of care and informa-
tion about delivery complications [14]. This study dem-
onstrates that these hypotheses bear out in the empirical
literature: when skilled providers do more for ANC cli-
ents, it increases the odds of their retention in SBA.
There were strong associations between SBA retention
and recommended ANC visit components including
blood pressure checks, the conduct of blood or urine
tests, receiving at least one tetanus injection, and receiv-
ing information about pregnancy complications. In
addition, when mothers had at least 4 contact points
Table 1 Surveys from 28 study countries included in the
analysis
Country Year Number
Benin 2011–2012 7,295

Burkina Faso 2010 3,294
Burundi 2010 4,698
Cameroon 2011 2,553
Chad 2014–2015 1,965
Comoros 2012 1,813
Congo 2011–2012 4,943
Democratic Republic of Congo (DRC) 2013–2014 6,439
Ethiopia 2011 2,876
Gabon 2012 2,891
Gambia 2013 4,378
Ghana 2014 3,431
Ivory Coast 2011–2012 4,084
Kenya 2014 6,184
Lesotho 2014 2,173
Liberia 2013 4,098
Madagascar 2008–2009 3,443
Mali 2012–2013 3,271
Mozambique 2011 4,768

Namibia 2013 1,972
Niger 2012 6,240
Nigeria 2013 11,072
Sierra Leone 2013 5,154
Swaziland 2006–2007 1,092
Tanzania 2010 4,137
Togo 2013–2014 1,999
Zambia 2013–2014 7,860
Zimbabwe 2010–2011 1,251
Total 115,374
Page 5 of 10
with skilled providers during ANC, they were more
likely to be retained in SBA. It may be that mothers per-
ceive skilled care to be of higher quality when they
receive recommended services. Taken together, these
findings suggest that improved ANC quality may in-
crease SBA coverage in African countries, potentially re-
ducing maternal mortality.
Receiving ANC in a facility from a skilled provider
reduced the odds of returning for SBA, after adjusting
for demographic characteristics and the quality of

ANC received. This finding may be explained by
facility-level factors such as lack of privacy during
consultations and long waiting times in facilities [15],
[16], [17]. Further research is needed to explore the
interactions between facility care and the maternal
client experience.
This analysis has several limitations. Firstly, while the
DHS program has extensive experience conducting sur-
veys in low and middle-income countries, these data
depend on self-reported information by respondents
and are thus subject to recall bias. Secondly, it may
have been beneficial to consider other determinants of
maternal care access such as subjective perception of
care quality, the autonomy of antenatal and delivery
care decision-making, and characteristics of maternal
health care providers such as years of experience and
use of job aids in service delivery. These variables were
either not collected in the DHS or elicited only in a
subset of the countries considered in this analysis.
Thirdly, this analysis is based on pooled cross-sectional
data and we are not able to make causal claims about
the impact of quality of ANC on the retention of clients
in SBA. It is also important to note that this study
Table 2 Characteristics of 115,374 births included in the study
sample
Variable Mean Standard Error
(N = 115,374, weighted
N = 115,453.5)
Retention in SBA among ANC
clients

0.66 0.0017
Antenatal Care (ANC) Characteristics
Blood pressure checked at
least once during ANC
0.87 0.0012
Any urine test conducted
during ANC
0.70 0.0016
Any blood test conducted
during ANC
0.79 0.0015
Told about pregnancy
complications during ANC
0.61 0.0018
Attended up to 4 ANC visits 0.63 0.0018
Received at least one tetanus
injection during ANC
0.84 0.0013
Received ANC in health
facility
0.86 0.0013

Demographic Characteristics
Has health insurance 0.07 0.0010
Lives in an urban area 0.39 0.0018
Belongs to the richest two
wealth quintiles
0.44 0.0018
Partner has any primary
education or higher
0.67 0.0017
Any primary education
or higher
0.63 0.0017
Aged between 18 and
35 years
0.81 0.0014
Primiparous (first birth) 0.18 0.0014
Grand multiparous
(more than 5 previous births)
0.22 0.0015
Country Indicators
Benin 0.06 0.0008

Burkina Faso 0.03 0.0006
Burundi 0.04 0.0007
Cameroon 0.02 0.0005
Chad 0.01 0.0005
Comoros 0.02 0.0005
Congo 0.04 0.0009
Democratic Republic of
Congo (DRC)
0.06 0.0010
Ethiopia 0.02 0.0007
Gabon 0.02 0.0007
Gambia 0.04 0.0007
Ghana 0.03 0.0006
Ivory Coast 0.04 0.0007
Kenya 0.05 0.0009
Table 2 Characteristics of 115,374 births included in the study
sample (Continued)
Lesotho 0.02 0.0005
Liberia 0.03 0.0007

Madagascar 0.03 0.0006
Mali 0.03 0.0005
Mozambique 0.04 0.0006
Namibia 0.02 0.0004
Niger 0.06 0.0008
Nigeria 0.10 0.0010
Sierra Leone 0.05 0.0007
Swaziland 0.01 0.0003
Tanzania 0.04 0.0007
Togo 0.02 0.0005
Zambia 0.07 0.0009
Zimbabwe 0.01 0.0003
Notes – SBA Skilled birth attendance
Page 6 of 10
investigates skilled care use across the maternal care
continuum specifically. Thus, comparisons of coverage
levels in this study to those reported in surveys on care
provided across a range of providers, particularly for

antenatal care, must be done with caution. Future re-
search on this subject would also benefit from the ex-
ploration of country-level factors that explain coverage
gaps, testing the impact of improvements in antenatal
quality on skilled birth attendance, and triangulating
self-reported care quality information with visit obser-
vations or clinical vignettes.
This study of SBA retention among ANC clients in-
cludes 28 African countries, covering a population of
740 million people. The study findings indicate that
current efforts to expand coverage of SBA across the
continent and reduce maternal mortality may benefit
from quality improvement efforts within ANC. In the
light of these findings, global and regional responses to
the recent call to action by maternal health experts that
urges for priority to be given to the provision of quality
maternal health services in the universal health coverage
agenda are critical [18].
Conclusions
About one-third of the ANC clients in Africa drop
out of the maternal skilled care continuum before de-
livery. Dropout from SBA is more likely to occur
when mothers do not receive good quality of care
during their ANC visits. Thus, quality improvement
efforts within ANC may serve to increase retention in
SBA, when the risk of death peaks, reducing prevent-
able maternal death in Africa.
Table 3 Fully-adjusted multilevel logistic regression model of
SBA retention among ANC clients
Variable Odds Ratio 95% Confidence
Interval

Antenatal Care (ANC) Characteristics
Blood pressure checked at least once
during ANC
1.18 1.10–1.27
Any urine test conducted during ANC 1.55 1.46–1.65
Any blood test conducted during ANC 1.31 1.22–1.40
Told about pregnancy complications
during ANC
1.18 1.12–1.24
Attended up to 4 ANC visits 1.57 1.51–1.65
Received at least one tetanus injection
during ANC
1.12 1.06–1.19
Received ANC in health facility 0.88 0.82–0.96
Demographic Characteristics
Has health insurance 1.79 1.57–2.04
Lives in an urban area 3.31 3.08–3.56
Belongs to the richest two wealth
quintiles
1.89 1.78–2.02

Partner has any primary education
or higher
1.37 1.30–1.45
Any primary education or higher 1.44 1.36–1.53
Aged between 18 and 35 years 0.94 0.89–0.99
Primiparous (first birth) 1.66 1.56–1.77
Grand multiparous (more than 5
previous births)
0.84 0.80–0.89
Country Indicators
Benin Reference Category
Burkina Faso 0.11 0.08–0.14
Burundi 0.20 0.16–0.24
Cameroon 0.09 0.07–0.12
Chad 0.02 0.02–0.03
Comoros 0.52 0.39–0.68
Congo 0.63 0.49–0.81
Democratic Republic of Congo (DRC) 0.06 0.04–0.07
Ethiopia 0.01 0.01–0.01

Gabon 0.26 0.20–0.35
Gambia 0.06 0.05–0.08
Ghana 0.07 0.05–0.09
Ivory Coast 0.09 0.08–0.12
Kenya 0.06 0.05–0.07
Lesotho 0.16 0.13–0.20
Liberia 0.06 0.05–0.08
Madagascar 0.07 0.06–0.09
Mali 0.20 0.16–0.26
Mozambique 0.01 0.01–0.01
Namibia 0.30 0.23–0.39
Table 3 Fully-adjusted multilevel logistic regression model of
SBA retention among ANC clients (Continued)
Niger 0.05 0.04–0.06
Nigeria 0.04 0.03–0.04
Sierra Leone 0.08 0.06–0.10
Swaziland 0.09 0.07–0.12
Tanzania 0.05 0.04–0.07
Togo 0.12 0.09–0.15

Zambia 0.10 0.08–0.12
Zimbabwe 0.05 0.04–0.06
Intercept 3.70 3.02–4.53
Cluster-level variance 1.31 1.24–1.38
Explained cluster-level variance in %
(relative to empty model)
65.87
Intraclass correlation or ICC (cluster-level) 0.28
Wald Chi2 9,060.74
N 115,374
Notes – SBA Skilled birth attendance
Page 7 of 10
T
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Page 8 of 10
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Ex
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cl
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%
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Sk
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b
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d
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ce
Page 9 of 10
Abbreviations
ANC: Antenatal care; CI: Confidence interval; DHS:
Demographic and health
surveys; DRC: Democratic Republic of Congo; ICC: Intraclass
correlation;
IRB: Institutional Review Board; OR: Odds ratio; SBA: Skilled
birth attendance;
Var: Variance
Acknowledgements
The findings, interpretations, and conclusions expressed in this
paper are
those of the authors and do not necessarily represent the views
of The
World Bank, its executive directors, or the governments that
they represent.
Funding
Not applicable.
Availability of data and materials
The datasets analyzed for the current study are available in the
Measure DHS
program repository [19]
Authors’ contributions

AC conceptualized and designed the study, analyzed and
interpreted the
data, and drafted the manuscript; ACW was involved in analysis
and
interpretation of the data, and revision of intellectual content of
the
manuscript; CM was involved in drafting of manuscript,
interpretation of the
data, and revision of intellectual content of the manuscript; KW
was involved
in conceptualizing the study, reviewing the literature, and
revision of
intellectual content of the manuscript. All authors read and
approved the
final manuscript.
Authors’ information
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was a secondary analysis of anonymous data from
the
Demographic and Health Survey database. Procedures and
questionnaires
for standard DHS surveys have been reviewed and approved by
the ICF
International Institutional Review Board (IRB). Additionally,
country-specific
DHS survey protocols are reviewed by the ICF IRB and
typically by an IRB in

the host country. The ICF International IRB ensures that the
survey complies
with the U.S. Department of Health and Human Services
regulations for the
protection of human subjects (45 CFR 46), while the host
country IRB ensures
that the survey complies with laws and norms of the nation [19].
Informed
consent was obtained from respondents during the survey while
formal ap-
proval to use the data was obtained from the DHS program. It
was deter-
mined that this study is not human subject’s research by the
Office of
Human Research Administration, Harvard T. H. Chan School of
Public Health
(IRB16-2047). Administrative permissions were required and
obtained from
the DHS program to access the data used in this study.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Author details
1Harvard T.H. Chan School of Public Health, 677 Huntington
Avenue, Boston,
MA 02115, USA. 2World Bank Group, 1818 H St. NW,
Washington, DC 20433,
USA. 3Johns Hopkins Bloomberg School of Public Health, 615
North Wolfe
Street, Baltimore, MD 21205, USA. 4Health Policy Research
Group, College of
Medicine, University of Nigeria, Enugu, Nigeria.

Received: 31 December 2016 Accepted: 19 May 2017
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Obstetric complications
in grand and great grand multiparous women. J Matern Fetal
Neonatal
Med. 2010;23(10):1211–7.
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increasing birth in the
health facility and reducing maternal mortality: a systematic
review. Ethiop J
Health Sci. 2014;24(0 Suppl):93–104.
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systematic review. Glob Health. 2015;11:36.
16. Finlayson K, Downe S. Why do women not use antenatal
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17. Ganle JK, Parker M, Fitzpatrick R, Otupiri E. A qualitative
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18. Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell
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19. The DHS. Program. 2016.
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cfm. Accessed 12 December 2016.
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https://data.unicef.org/
http://dhsprogram.com/data/available-datasets.cfm
http://dhsprogram.com/data/available-
datasets.cfmAbstractBackgroundMethodsResultsConclusionsBac
kgroundMethodsStudy SampleStudy VariablesStatistical
AnalysisResultsDiscussionConclusionsAbbreviationsAcknowled
gementsFundingAvailability of data and materialsAuthors’
contributionsAuthors’ informationCompeting interestsConsent
for publicationEthics approval and consent to

participatePublisher’s NoteAuthor detailsReferences
ORGANIZATIONAL CHANGE AT ST. JOSEPH HOSPITAL
a case study from a student=s lab assignment
However, one precondition of the nurses working
on the new CU was, that they did not have to handle
preparation of the chemotherapy. Thus, it fell to the
already over-worked physicians to prepare the
treatment solutions every day and they also had to be
trained to do this. It became rapidly clear that with the
success and rising number of cancer patient
admissions to the CU, this professional group was
simply overwhelmed with the task. Therefore, we
suggested that the hospital pharmacy, which
distributed and prepared all other medications, should
take over the preparation of chemotherapy solutions.
The head pharmacist objected to this vigorously and
nothing happened for a year. However, in the
meantime the management of the hospital saw the
success of the CU, which more and more was able to
reach out to the community through cancer survivors
who founded self-help groups and therefore gained in
popularity. In addition, the special benches for the
preparation of chemotherapy became outdated and
therefore, had to be replaced. We made the argument,
that the buying of new benches for all wards (since
some cancer patients were still treated on other units)
would not be necessary if the hospital pharmacy
would take over the preparation centrally. After
another six months the head pharmacist finally gave
in, got a special bench installed and started with the
central preparation of chemotherapy solutions.

Background and Change Processes
When I came to St. Joseph Hospital in 1993, 1
was hired as chief resident to build up an oncology
unit in the Department of Gastroenterology, which
had not existed until that date. While the hospital had
treated cancer patients before, it was not prepared to
do this on a larger scale and basically referred the
respective patients to other hospitals. This changed
with the arrival of a new director of the department
who had some experience with the treatment of
gastrointestinal (GI) malignancies at his former post.
With regard to the growing incidence of cancer in the
over-aged population of the city, he also saw a
chance to increase the attractiveness of the hospital
for the community.
Subsequently we rededicated a ward with 18
beds to be the assigned 'Cancer Unit' (CU), after the
nurses working on that ward had agreed to that
change. (Actually, the unit was planned for another
ward in the beginning but the nurses on that ward had
refused the change.) Within a short time, an attending
physician board-certified in hematology/oncology
was hired and we both started to train the nursing
staff for the special requirements that cancer patients
have. We also were able to hire a psychologist for the
counseling of the patients as well as for supervision
of a Balint group (an exchange between staff about
their experience and to cope with the stress) and
counseling of the staff. Then we concentrated all
cancer patients, who were already treated in the
hospital, on this ward. Word of the new unit spread
and was met mostly with skepticism in the hospital
and applause by the surrounding health practitioner

community. Patients started being referred to us more
and more and within six months after its' erection the
ward was completely filled with cancer patients.
Stage of Change
The process, as far as I know, is still in the
maintenance stage. All changes have taken place and
are perceived as success. The physicians have more
time to concentrate on their special clientele and the
ordering and distribution of chemotherapy is smooth.
Even the pharmacist and especially his assistant (who
right from the beginning was much less opposed to
the idea) are satisfied since they got the new bench
and felt that the preparation now is in good hands.
Until the arrival of the new head of the
department the cancer patients had been spread over
all wards in the two internal medicine departments,
which did not ensure a high quality of their treatment
because of the inexperience of the respective
residents in hematology/oncology. The preparation of
the chemotherapy, mostly very toxic substances, until
that time was taken over by the respective nurses of
the wards, who previously had just been given a short
introduction to take special care with the preparation.
Since the chemotherapy was prepared on all medical
wards in the hospital, a number of special laminar
airflow benches had to be bought to comply with
federal regulations regarding toxic substances and
their use in me country.
Organizational Diagnosis
The Technical Factor

Chemotherapy: toxic substances, dangerous to
handle
The logistics: distribution , utilization of larger
amounts of medications
Erection of a laminar airflow bench in the
pharmacy
Information systems: recording and reporting
Necessary overhaul of existing chemotherapy
Module 5: Organizational Change & Development: 20
benches on wards
The Human Element
Resistance of nurses to prepare drug solutions
Reluctance of pharmacy to introduce central
preparation
Workload of physicians
Decreasing chance for mistakes by professionals
and central handling of toxic substances
Conservatism of catholic hospital leaders =>
skepticism towards change
The Environment

Attractiveness/reputation of the hospital for
referring health practitioners
Popularity/reputation of hospital with
surrounding community
Location of hospital in a district with many older
citizens
Space-Time coordinates
Timing of inputs: training of people who prepare
solutions, drug supply for perceived need
Timing of distribution of chemotherapy to CU
Locations of 'players' in the building
(communication)
Location of hospital with regards potential
clientele (mostly older people)
Policy Factors
Federal regulations regarding preparation and
handling of chemotherapy drugs
Necessity of hospital in our city - increased
chance to survive 1990s 'hospital dying'
Application of chemotherapy - lucrative business
for the hospital
Competition among heads of departments for
resources (human and financial)

Cost of new laminar airflow benches for all
wards
Pressure for professional handling of hospital
affairs by government, medical associations etc.
Conclusions and Lessons
In my opinion the approach to the problem was
appropriate. The new CU was a success and meant an
increase of popularity of the hospital for the referring
health care providers an d the community, since
patients could now be treated nearby. This impressed
the conservative hospital council, which was initially
opposed to a special ward for the disease (fear of
stigmatization ) and of the administration who
initially feared rising costs. While the costs indeed
rose, the hospital still made more money since cancer
treatment is rewarded more generously in the country
and due to the more complete treatment offerings and
increased popularity of the hospital more patients
came, also for other illnesses.
A problem was the inner-hospital structures of
power. While the parallelism of structures may
obstruct changes (especially those concerning two or
more of the structures), it is the reality nowadays in
most hospitals in the country and has it s advantages
(better teamwork between nurses and physicians,
nobody feels superior). Since the pharmacy and the
nursing section were 'emancipated' with regard to the
physicians, the only way to achieve change was
gradual persuasion. The success of the CU and the
backing by the hospital management certainly helped

in convincing the head pharmacist to take over the
task. At the same time, there was fortunately political,
scientific, and technical pressure for more
professionalism in handling chemotherapy
preparation in the country.
Organogram of St. Joseph Hospital
Hospital Council and Board of
Trustees

Medical Director
Head of
Nursing
Head of
Pharmacy
Administrative
Director

Directors of
other depts
Director of
Medical
Department II
Director of
Medical
Department I

other Depts:
Obs/Gyn,
Surgery,
Radiology,
etc.
Departments of

Neurology,
Cardiology
Depts of
Gastro-
enterology,
Hematology,
Oncology
Nurses
Pharmacy
Administration

Diagnostic
Procedures
Other Wards
Cancer
Unit
SOCIAL AND BEHAVIORAL FOUNDATIONSOrganogram of
St. Joseph HospitalTIME MANAGEMENTPOLICIES

INFLUENCE HEALTH WORKER BEHAVIOURDifferent
Organizational Assumptions and
ApproachesEvaluationBenefitPercentReferral System 1.3
Please use this proposal form only; submissions not using this
format will not be accepted
604.771.86 – Social & Cultural Basis for Community and
Primary Health Programs
Lab 4: Organizational Diagnosis Worksheet
Name:
(Due to peer grading, this is an individual assignment)
Please use this form for your assignment.
1. Briefly describe the name, location and functions of the
organization being diagnosed. Include a description of the
problem issue and state the stage of change the organization is
in, related to recognizing and/or addressing the problem, and
justify your choice of stage. (5 points)
2. Append an organogram (organizational chart) of the
organization, highlighting your place in the scheme of things.
One can use computer graphics or scan and insert an hand
drawn version. (5 points)
3. Write out an organizational diagnosis related to the problem
issue in the table below.
Diagnostic Element
Detailed Indicators of the Problem

3.1 Human (5 pts)
3.2 Environmental (5 pts)
3.3 Technical (5 pts)
3.4 Policy (5 pts)
3.5 Time-Space (5 pts)
4. Suggest strategies and solutions to the problem just
diagnosed. (5 points)
(note: you will receive an additional 5 points for doing the peer
assessment)

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