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
• 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)
• 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)
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)
• 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.
V i e ntia ne
H u a p h an h
Sa v a nn a k het
X a y ab ur y
L u a ng pr a ba n
P ho n g s al y
K h a m mu a ne
Atta peu
B o k e o
C h a mp as a c k
X i e n g kh u a ng
B ol i k ha m xa y
Ou d o mx a y
Sar a va neSe k o n g
L u a ng n a mt h a
X a y so m bo o n
V i e ntiane C a pital
Selected
Study site
(4)
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
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
Results
Distance far from health
facility
Table 1: Socio-demographics and place of delivery
*8,767 kip is equal to US$ 1 (8)
(n=311) %
Age (year) Mean (SD)13-2425-48
25.7 (6.1)150161
48.252.8
Ethnicity Lowland Lao (Lao Lum)Midland Lao (Lao Thung)Highland Lao (Lao Sung)
232790
74.625.40.0
Household income (Kip)*/ month Mean (SD)>300,001 <300,000
1.7 (0.5)21497
68.831.2
Education of mothers Illiterate Educated
68243
21.978.1
Education of fathers Illiterate Educated
50261
16.1 83.9
Occupation of fathers Farmer Government official Daily wage worker
1775084
56.916.127.0
Number of children Mean (SD)≤2>2
2.6 (1.9)190121
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)189113
63.736.6
Place of delivery Hospital Home
159152
51.148.9
Table 2: History of reproductive health and antenatal care
(n=311) %Parity Mean (SD)
≤2>2
193118
2.6 (2.0)62.137.9
Gravida Mean (SD)≤2>2
179132
2.8 (2.1)57.642.4
Abortion Mean (SD)Never had abortion Had abortion
25952
0.2 (0.5)83.316.7
Attend antenatal clinic during the last child
Yes No
207104
66.633.4
Times and attended ANC during pregnancy (207)
Mean (SD)≤ 4> 4
12879
4.3 (1.9)61.838.2
Antenatal card or booklet Yes No
14859
71.428.6
(9)
Table 3: Factors influencing place of delivery
a8,767 kip is equal to US$1
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)
13.7 (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)
12.4 (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)
15.1 (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)
14.1 (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)
14.2 (2.4-7.4)1.4 (0.6-2.7)
10.000***0.001***
(10)
Table 4: Factors influencing place of delivery
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)
12.3 (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)
12.3 (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)
13.5 (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)
17.3 (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)
11.9 (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)
12.5 (1.4-4.7) 0.003**
(11)
OR= Odd ratio; AOR= Adjusted odds ratio by Binary Logistic Regression
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)
11.3 (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)
11.0 (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)
10.5 (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)
18.3 (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)
10.5 (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)
12.3 (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)
10.5 (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)
12.3 (1.0-5.1) 0.042*
(12)
Table 5: Regression analysis: Factors influencing place of delivery
Discussion
• 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
• 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
• 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
Thank you
