We present the sample characteristics highlighting the relative changes in utilisation of antenatal and skilled birth deliveries service among primigravidas in the MDG period in Uganda. We also present the independent effect of policy changes (captured in year of survey), predisposing factors, and enabling factors, and then conclude the section with a closure look at the changing influence of age and geographical disparities in maternal health services utilisation in 2006, 2011 and 2016.
The sample characteristics are presented in Table 1. The study found marginal improvement in early ANC utilisation. For instance, while about 23% had ANC in the first 8 weeks of pregnancy in 2006, about 29 and 31% achieved this target in 2011 and 2016, respectively, with an average of 29% having early ANC in the last 10 years of the MDGs. Also, the proportion of primigravidas who had 4+ ANC visits increased slightly from 58% in 2006 to 59% in 2011, and further to 65% in 2016. On the average, 62% of primigravidas utilised 4+ ANC visits from 2006 to 2016. Access to SBAs however improved remarkably. In 2006, 65% of primigravidas accessed SBAs, but this jumped to 87% in 2016 after rising to 78% in 2011.
Analysis of the pooled data shows that 80% of primigravidas accessed SBAs between 2006 and 2016. These findings are similar to the maternal health services utilisation trends in the country , except that primigravidas’ access to ANC is lower while their utilisation of SBAs is higher than the general population. The study showed heterogeneities in predisposing and enabling factors to healthcare use among primigravidas as shown in Table 1.
Early antenatal care access
For brevity and to focus the paper on independent effects, we report only adjusted results from multivariate regression presented in Table 2. However, results from bivariate analysis are reported in Supplementary Table 1. The multivariate analyses show that primigravidas in 2011 were 30% more likely, and in 2016, 48% more likely to utilise early ANC compared to 2006. Predisposing factors such as educational attainment and age were associated with disparities in the utilisation of early antenatal services. Primigravidas with no formal education and those with secondary education or higher compared with their colleague with primary education were more likely to have early ANC (AOR = 1.54, p ≤ 0.001; and AOR = 1.15, p ≤ 0.1, respectively). Similarly, primigravidas above 25 years were more likely to utilise early ANC (AOR = 1.33, p ≤ 0.001) compared to those younger than 21 years. For enabling factors, household wealth and locational characteristics were associated with early ANC utilisation. In contrast with individuals from the richest households, those from the poorest and poor households were less likely to have early ANC (AOR = 0.77, p ≤ 0.1; and AOR = 0.76, p ≤ 0.05, respectively). Surprisingly, primigravidas in urban settings were about 18% less likely to utilise early ANC compared to their counterparts in rural areas. Further analysis (not reported here) revealed wealth disparities as explaining this seemingly counter-intuitive finding. Also, aside Southwestern region, which showed higher odds, all other regions reported lower odds of early ANC utilisation relative to North region.
Meeting 4+ antenatal care
Primigravidas were 24% more likely to access four or more ANC visits in 2016 than in 2006, with no statistically significant difference between 2011 and 2006. Consistent with early ANC, disparities in utilisation of 4+ ANC visits were associated with education and age. Primigravidas with secondary education were more likely to have 4+ ANC visits (AOR = 1.17, p ≤ 0.05) compared with those with primary education, while those aged 21–25 and 25 years or above were more likely to report higher odds of utilising 4+ ANC visits (AOR = 1.13, p ≤ 0.1; and AOR = 1.44, p ≤ 0.001, respectively) relative to younger primigravidas (below 20 years). However, unlike early ANC, other enabling factors in addition to wealth and locational factors showed statistically significant association with 4+ ANC visits. For example, primigravidas who were unemployed were associated with lower odds of having 4+ ANC visits (AOR = 0.88, p ≤ 0.1) compared with their counterparts in full employment. Similarly, primigravidas with lower level of household decision-making power (involves both males and females) were 19% less likely to utilise 4+ ANC visits relative to those with middle level (males only). Furthermore, primigravidas in rich (AOR = 0.73, p ≤ 0.001), middle (AOR = 0.76, p ≤ 0.05), poor (AOR = 0.65, p ≤ 0.001) and poorest (AOR = 0.67, p ≤ 0.001) households were less likely to access 4+ ANC visits compared to those in richest households. Just as in early ANC, urban compared to rural residence was associated with lower odds of utilising 4+ ANC visits (AOR = 0.86, p ≤ 0.1), while Eastern and Western regions compared to North region were less likely to utilise 4+ ANC visits (AOR = 0.83, p ≤ 0.1, and AOR = 0.81, p ≤ 0.1, respectively).
Skilled birth attendance (SBAs) utilisation
Access to SBA showed the highest improvement in the decade to the end of the MDG period in the study. Compared to 2006, primigravidas were 46% more likely in 2011, and about 3 times more likely to utilise skilled delivery services in 2016. Again, education and age were the only statistically significant predisposing factors predicting access to SBAs. While primigravidas with secondary education or higher were more likely (AOR = 2.34, p ≤ 0.001), those with no formal education were less likely to have SBAs (AOR = 0.76, p ≤ 0.001) compared to their counterparts with primary education. Similarly, older primigravidas (> 25 years) were more than 2 times more likely to utilise SBAs relative to younger primigravidas (≤20 years). The influence of enabling factors was particularly more pronounced in SBAs than in antenatal care. Here, financial and physical burden of health care access, which were less important in antenatal care use, gain prominence in skilled delivery service utilisation. Primigravidas with huge physical challenge in accessing healthcare were less likely to utilise SBAs (AOR = 0.83, p ≤ 0.05) than those with less physical challenge. However, financial burden being a huge challenge to healthcare was rather associated with higher likelihood of utilising SBAs (AOR = 1.19, p ≤ 0.1). In addition, primigravidas with higher level of decision-making power were less likely to use skilled delivery services than those with middle level of decision-making power (AOR = 0.63, p ≤ 0.1). Wealth and geographical disparities also influence access to SBAs in this study.
Counting progress against the WHO recommended maternal health indicators
The standard of measuring progress in the MDG period was the WHO recommendation that every woman should utilise antenatal care service in the first trimester of pregnancy, have at least 4 antenatal visits before delivery and utilise skilled delivery services during delivery. Taken together, primigravidas were 42% more likely to meet the WHO recommendation in 2016 compared to 2006. Nonetheless, disparities were found along predisposing (i.e. education and age), and enabling factors (i.e. household wealth, employment status and region of residence). Higher educational attainment (secondary+) compared to primary education, and primigravidas above 25 years compared to those aged ≤20 were more likely to meet the WHO recommended maternal health services utilisation (AOR = 1.16, p ≤ 0.001; and AOR = 1.25, p ≤ 0.001, respectively). In addition, Primigravidas in poorest, poorer, and middle wealth households were less likely to meet the WHO recommendation compared to those in the richest households (AOR = 0.81, p ≤ 0.05; AOR = 0.80, p ≤ 0.001; and AOR = 0.84, p ≤ 0.05, respectively). Individuals in temporary employment where less likely to meet the WHO recommended maternal health services utilisation (AOR = 0.90, p ≤ 0.1) than those in full employment. Similarly, while primigravidas in Central 2, Eastern and Western regions were less likely, those in Southwestern were more likely to meet the WHO recommended maternal health services utilisation service level compared to their counterparts in North region (AOR = 0.81, p ≤ 0.05; AOR = 0.73, p ≤ 0.001; AOR = 0.86, p ≤ 0.1, and AOR = 1.17, p ≤ 0.1, respectively). Surprisingly, rural-urban inequalities were less important in the attainment of the WHO recommended maternal health services utilisation.
Closer look at age and geographical disparities in antenatal care and SBAs use over time
As indicated in Fig. 2, the study found that much of the improvement in access to early antenatal visits and skilled birth delivery was between 2006 and 2011, but for 4+ antenatal visits and meeting the three WHO recommended maternal health indicators, a significantly greater improvement was seen between 2011 and 2016.
Age disparities was associated with access to maternal health services. For instance, a primigravida aged 45 was about two times more likely to access early ANC and about three times more likely to meet all three WHO recommended maternal health services compared to their counterpart aged 15 in 2016. Among all the maternal health indicators, the greatest improvement was reported in access to SBAs – a change in probability from 0.61 for 15-year old primigravida in 2006 to 0.98 for 45-year old primigravida in 2016. In contrast, the lowest improvement was reported in access to all the WHO recommended maternal health services with a change in probability from 0.11 for primigravidas aged 15 in 2006 to 0.41 for those aged 45 in 2016.
Similar dynamics were revealed across geographical regions over the three-time periods (see Fig. 3). Overall, the lowest probability of accessing early ANC and the WHO recommended maternal health services was reported in Eastern region. Central 1 and Western had the lowest probability in utilisation 4+ ANC and SBAs, respectively.
In contrast, the highest probabilities of accessing early ANC visit and all the WHO recommended maternal health services were reported in South West region, and for 4+ ANC and SBAs in West Nile region.