| dc.description.abstract | Introduction: Studies on determinants of maternal health services such as Antenatal Care (ANC), Delivery
care (that is, Facility delivery or facility-based delivery) and postnatal care (PNC) in Uganda have all
applied conventional methods of data analysis such as chi-square and logistic regression analysis
irrespective of the hierarchical structure of the population. This leads to biased estimates due to the
clustering effect within the population. To fully understand and provide reliable statistics for policy and
planning, this study investigated the determinants of maternal health services utilization (MHSU) using
multilevel modeling. It further determined out the effect of four or more ANC visits on facility delivery and
early postnatal care utilization using propensity score matched analysis (PSMA).
Methods: Secondary analysis of data from the Uganda Demographic and Health Survey (UDHS) of 2016
among women who gave birth three years preceding the survey, aged 15 – 49 years was done. UDHS data
are collected based on multistage sampling technique and thus data are clustered within primary sampling
units (called communities in this study). The data analysis started from the descriptive analysis of the
sample statistics, followed by bivariate analysis between the outcome variables and the determinants to
identify significant associations between the outcomes and determinants that were used in multivariable
analysis. Multilevel modelling began by fitting a null model and used it to check whether multilevel
modelling was necessary using the Likelihood Ratio Test (LRT) and intra-class correlation (ICC). Level 1
(individual), level 2 (household) and level 3 (community) models were then fit. For the number of ANC
visits (0 – 1 ANCs = 0, 2 – 3 ANCs = 1, 4 or more ANCs = 2), a multilevel ordinal logistic regression
model was fit. For facility delivery (yes = 1, no = 0), the multilevel binary logistic model was fit. For timing
(less than 48 hours = 1 or 48 hours or more and no PNC = 0) of postnatal care services utilization, the
multilevel binary logistic model was fit. To examine the variations in individual and household level
determinants on MHSU across type of place of residences, analysis was done by stratification by rural and
urban residences. PSMA using radius caliper and kernel matching was used to obtain the Average
Treatment Effect of the Treated (ATT).
Results: The study found out that mother’s level of education (secondary or higher) [AOR = 1.37, 95% CI:
1.12, 1.68], mass media exposure [AOR = 1.27, 95% CI: 1.10, 1.47], last birth caesarean [AOR = 1.47,
95% CI: 1.08, 2.00] and high household wealth index [AOR = 1.39, 95% CI: 1.14, 1.70] were all associated
with ANC utilisation. Mother’s level of education was also found to be associated with both facility delivery
[AOR = 2.03, 95% CI: 1.51, 2.73] and EPNC [1.50, 95% CI: 1.13, 2.00]. Four of more ANC visits is also
associated with both facility delivery [AOR = 4.87, 95% CI: 3.29, 7.21] and EPNC [AOR = 17.39, 95%
CI: 13.84, 21.85]. For factors associated with utilisation of maternal health services by type of place of
residence, the study found out that mother’s level of education influenced ANC utilisation in urban [APR
= 1.65, 95% CI: 1.02, 2.65] and in rural [APR = 1.58, 95% CI: 1.22, 2.05] areas respectively. Four or more
ANC visits was found to be positively associated with facility delivery in urban [APR = 1.34, 95% CI: 1.01,
1.78] and in rural [APR = 1.87, 95% CI: 1.54, 2.26]. Facility delivery is strongly associated with utilisation
of EPNC in urban [APR = 4.40, 95% CI: 2.55, 7.62] and in rural [APR = 6.03, 95% CI: 4.98, 7.29]. The
probability of facility delivery and EPNC is [ATT = 0.118, 95% CI: 0.063, 0.173] and [ATT = 0.099, 95%
CI: 0.076, 0.121] respectively higher among women who have had 4 or more ANC visits, to the same
women had they not had 4 or more ANC visits. The probability of EPNC was [ATT = 0.518, 95% CI:
0.489, 0.547] among women who have had facility delivery compared to those who have not.
Conclusions: Different woman and household level factors such as mother’s level of education,
employment status, distance to health facility, modern contraceptive use, mass media exposure, birth order
number, household wealth index, and community level factors, that is type of place of residence and region
are associated with maternal health services utilisation in Uganda. The results from propensity score
matched analysis illustrate the need for implementation of policies towards provision of ANC services (at
least four ANC visits) since it plays an effective intervention to increase facility-based delivery and
ultimately early postnatal utilisation. | en_US |
