Maternal and neonatal service usage and determinants in fragile and conflict-affected situations: a systematic review of Asia and the Middle-East

Using the criteria shown in Table 1, eight low- and middle-income FCS were selected (i.e. Afghanistan, Iraq, Myanmar, Nepal, the Palestinian Territories, Syria, Timor-Leste, Yemen). As FCS were defined through national scoring, no attempt was made to include additional countries with sub-national areas of fragility (e.g. India) that did not fulfil scoring criteria. A pre-designed protocol guided the review processes, including search strategy, study selection, data extraction, quality assessment, and data synthesis. Reporting uses PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines [13]. This review is registered with PROSPERO (International Prospective Register of Systematic Reviews) at the National Institute of Health Research, USA, as CRD42014014537 [14].

The literature search was conducted in April 2014. First, authors searched electronic databases Embase, PubMed, and Web of Science systematically. Second, authors purposefully searched agency websites of Asian Development Bank, DFID, OECD, World Bank, and WHO. Third, authors identified potentially relevant citations from included studies and hand-searched them in relevant journals identified. Search strategies and terms were adapted as appropriate for each database and site, with a combination of MeSH and non-MeSH terms using Boolean operators “AND” and “OR”. Key search topics were:

“maternal health/care” [MeSH] OR “childbirth” [MeSH] OR “institutional delivery” OR “skilled birth attendance” OR “antenatal /prenatal” OR “postnatal/postpartum ” OR “neonatal/perinatal/newborn” OR “infant” OR “child care/health” or “under-five care/health” AND “fragile setting/context” OR “crisis setting” OR “conflict-affected region/areas” OR “Afghanistan” OR “Nepal” OR “Myanmar/Burma” Or “Timor-Leste/East Timor” OR “Yemen” OR “West Bank and Gaza/Palestine/Palestinian Territories” OR “Iraq” OR “Syria” OR “ Asia” OR “ Middle-East”

Policy evaluations, reviews and discussion papers were excluded. Studies given a low quality-score during methodological assessment were also excluded. The first author reviewed title, abstract and key words of all articles retrieved. Those articles meeting eligibility criteria were selected for full review. A second author checked selection of relevant abstracts and full articles. Any disagreements prompted another round of scrutiny until consensus was reached.

Data were extracted from each record into an Excel spreadsheet. Headings included: lead author, co-authors, year of publication, type of source (e.g. PubMed, website), study setting, study design, outcomes of interest, number and type of participants, participant selection criteria, sample size, data analysis and reporting, limitations, and methodological quality score.

Study outcomes were restricted to service-usage for any of antenatal care (ANC), institutional delivery, skilled birth attendance (SBA), emergency obstetric and neonatal care (EmONC), postnatal care (PNC), early breastfeeding, newborn consultation for any perceived morbidity, and newborn vaccination. Any ANC was considered (e.g. any visit, all four visits, ANC from a skilled or unskilled provider). For PNC, any visit and PNC from a skilled or unskilled provider were considered. Factors affecting maternal and neonatal health services usages were included in the synthesis.

Authors adapted the McGill University Mixed-Methods Appraisal Tool (MMAT) [15], which has been used to assess methodological quality of both mixed-methods and primary cross-sectional studies (Table 2). In adapting this tool, authors excluded irrelevant indicators (e.g. are measurements appropriate?) and included new ones (e.g. was there any recall bias in reporting data?). Nine indicators were considered for both quantitative and qualitative studies, with each scored 1 if present and zero otherwise. Summative scores indicated overall study quality (e.g. six and above was considered high quality, 4–5 medium quality, less than four low quality and therefore excluded). For mixed-method studies, the maximum summative score was 12 (i.e. nine and above was high quality, 6–8 was medium quality, less than 6 was low-quality and therefore excluded). Two authors assessed quality independently, with disagreements resolved by discussion.

Summary measures were percentages and odds ratios (ORs) with a confidence interval of 90, 95 or 99% significance. Based on the heterogeneity of data, a narrative synthesis was conducted, combining both qualitative and quantitative data. If feasible, quantitative data were subjected to meta-analysis using fixed effects with odds ratios pooled for similar determinants in particular services. Forest plots were generated for each determinant with odds ratios and confidence intervals displayed. Heterogeneity among studies was tested using I [1] statistics in Stata 13. Narrative synthesis was used for qualitative data on determinants of MNH service usage to describe and compare findings across settings, types of services and population groups.

Figure 1 details the stages of study selection. Initially, after removing duplicates 1319 records were identified as potentially relevant. After excluding irrelevant articles, 274 abstracts were screened, of which 36 were eligible for full text review. Finally, 18 peer-reviewed articles were selected for inclusion.

Table 3 shows that among 18 studies included, eight (44%) were from Nepal [16‐23], four (22%) from Afghanistan [24‐27], and two (11%) each from Iraq, Yemen, and the Palestinian Territories [28‐33]. Fourteen (77%) were quantitative studies (i.e. 11 cross-sectional surveys, 2 (11%) used national health survey data, 1 prospective cohort study), two (11%) were qualitative, and two (11%) used mixed-methods designs. All studies included met the required methodological quality criteria suggested by MMAT (Table 2) particularly for data collection, analysis, and reporting. Twelve (66%) studies received a high methodological quality score and 7 (38%) received a medium score. Studies exhibited a few minor quality issues as described below.

None of the quantitative studies was nationally representative or generalisable. Data analysis was not presented with considerable details in Devkota and Bhatta [17], Khorrami et al. [25], Mayhew et al. [20] or Najem and Al-deen [28]. Khorrami et al. [25], Mayhew et al. [20], Najem and Al-deen [28], Sharma et al. [21] and Ulak et al. [23] did not provide sufficient details on study settings. Three studies (e.g. Devkota and Bhatta [17], Karkee et al. [19], Shrestha et al. [22]) focused on remote fragile settings. Dhaher et al. [32], by examining factors affecting postnatal care in Palestine, reflected the status of postpartum women in a conflict-affected setting. Among qualitative studies, Rahmani and Brekke [27] did not triangulate information from several data sources.

Neither mixed-methods study (i.e. Kempe et al. [31], Basaleem et al. [30]) was nationally representative and generalisability was not addressed. Kempe et al. [31], did not give adequate description on the processes of data analysis or the necessity of using qualitative data. Basaleem et al. [30] used a mixed-methods design to explore maternal health and influence of women’s autonomy in Yemen. In this study, details on study setting and quantitative data analysis were not clearly explained, while statistical analyses of determinants were not in-depth [31].

Table 4 provides service-usage findings. Three studies (17%) described ANC usage [16, 17, 30]. Overall, at least one ANC visit was above 50% in both Nepal and Yemen [16, 17, 30]. More than 60% of Yemeni women obtained ANC from a professionally trained provider in the first trimester [16].

Five studies (27%) mentioned SBA usage [16‐18, 20, 31]. There was a sizable difference in SBA usage across studies from 13% in Nepal to 50% in Yemen [20, 30]. Kempe et al. [31] noted usage of untrained traditional birth attendants (32%) was much higher than of medical doctors (17%) or nurse-midwives (13%) in Yemen. Three studies discussed institutional delivery [17, 19, 33], which ranged from 85% in Nepal to 97% in Palestine [19, 33]. Giacaman et al. [33] noted that usage was higher for government (56%) compared to private (28%) facilities for childbirth in the Palestinian Territories.

Three studies (17%) discussed PNC, with less than 40% coverage found in Palestine, Yemen and Nepal [18, 30, 32]. More than 70 and 60% of those sampled received PNC from hospitals and trained physicians respectively [18]. Two studies (11%), from Nepal and Iraq, discussed newborn care [17, 23, 28]. Breastfeeding within an hour of delivery ranged from 7 to 57%. In Nepal and Iraq studies, 70% of mothers did not seek any professional advice on newborn health and 30% did not vaccinate newborns [16, 28].

Table 5 summarises findings on determinants of service usage. Determinants of SBA were discussed in three studies from Iraq and Nepal [16, 20, 29]. Women who depended on TBAs for delivery were generally less educated, less wealthy, and older [29]. Having at least four ANC visits, knowledge of pregnancy danger signs, residing near a facility, being wealthier and better-educated were demand-side factors increasing the probability of SBA usage [16, 20, 29]. Pooled odds ratios (Fig. 2) showed education was associated with a 20% increased odds of SBA usage (OR 1.2, 95% CI 1.07-1.33), whereas wealth quintile was not significant (OR 0.89, 95% CI 0.74-1.04). On the supply-side, having more than one female traditional birth attendant (TBA) and community health-worker in the community, and at least one female doctor and provision of antenatal and emergency obstetric care in the facility increased SBA usage [20]. Similarly, absence of user fees and availability of health insurance increased the odds of SBA usage [20]. Qualitative studies indicated that women’s autonomy over decision-making about her health and personal life was a decisive factor in using SBA [31]. However, despite having autonomy several nomadic women in Yemen reported not wanting SBA [26, 31]. Two studies (11%) indicated that informal payments restricted timely access to facility care among pregnant women [26, 31].

Determinants of facility-based delivery were discussed in five (27%) studies [19, 21, 22, 29, 33]. Usage was higher among women with at least one ANC visit, more education, younger, employed, belonging to higher-status social groups, and who resided near facilities and in physically-accessible areas [18, 19, 21, 22, 33]. Meta-analysis indicated education was a significant determinant across most studies. Pooled odds ratios showed education was significantly associated with a higher proportion of facility-based delivery (OR 2.78, 95% CI 1.63-3.94). Qualitative research in Yemen indicated women preferred facility-based delivery given adequate staff, medicines, emergency care, cleanliness and arrangements for labour induction and neonatal resuscitation [30]. Public hospitals were reportedly preferred by Yemeni women due to the presence of qualified staff. [30] However, some women preferred home delivery for feelings of security, family support, and lower costs [30].

Determinants of delayed EmONC was discussed in two (11%) studies [24, 25]. These included not attending any ANC, care-seeking from traditional healers, and not wanting facility-based delivery. Absence of a midwife in the community or a facility also contributed to delayed EmONC. One study showed that residing near a facility, availability of an automobile for travel, inexpensive services, and perceived availability of safe care at the facility all increased the odds of EmONC usage [25].

This systematic review synthesized the limited qualitative and quantitative evidence on maternal and neonatal service usage and its determinants in fragile and conflict-affected situations in Asia and the Middle-East. Relevant findings are similar to those in non-FCS, but more difficult to resolve given the unique challenges of FCS. These include disparities in the usage of essential MNH services among different socioeconomic, demographic and geographic groups even within FCS, with disadvantaged groups (e.g. women with no formal education, living at a distance from health facilities) facing additional barriers. This highlights the need to improve delivery of key MNH services (e.g. SBA, EmONC, PNC) in Asian and Middle-Eastern FCS. Similarly, recognised demand-side barriers from non-FCS, including lack of awareness, money, and transportation, still need to be sufficiently addressed in Asian and Middle-Eastern FCS. This review revealed evidence gaps in MNH in Asian and Middle-Eastern FCS, particularly for EmONC, PNC, newborn care, and service usage in acute-conflict situations.

Both low- and middle-income countries were included in this review, and usage of MNH services and their determinants were found to be similar across both categories. These findings reiterate the similarly limited healthcare infrastructure, service delivery and demand-side pre-disposing factors, found in FCS irrespective of national income [34, 35]. Most studies focused on remote and marginalised populations within FCS, which while useful in describing in-country social and political fragility, limited generalisability. No studies distilled MNH service-usage during acute conflict, though Afghanistan, Iraq and the Palestinian Territories included areas of acute conflict. Existing evidence indicates that even better-performing FCS are unable to effectively address MNH during recurrent crises [6, 36, 37]. Without ensuring EmONC and transportation services during acute crises, maternal and neonatal deaths in FCS will not be curtailed [6]. Additional research is needed to explore MNH services access and adaptive responses during acute crises (e.g. EmONC) to improve services sufficiently to achieve global MNH targets [36].

Evidence is particularly limited on usage of some essential maternal and neonatal health services for EmONC, PNC, and newborn care in the FCS of Asia and Middle-East. Overall, MNH service usage trends in Asian and Middle-Eastern FCS were similar to those found for FCS globally (e.g. low SBA and PNC usage) [38‐43]. Usage of all MNH services was low, though highest for ANC. However, data collection emphasised receiving any ANC rather than the 4+ ANC visits recommended by WHO. Thus, it is not possible to conclude that existing ANC usage is adequate in these FCS. More research is necessary on timing of first visit and completion of 4+ ANC visit [7, 20].

SBA usage differed significantly across studies within the same countries, though usage was universally low. This intra-country variation appears due to socioeconomic differences, with SBA usage higher in relatively wealthier areas within countries (e.g. Nepal). Additionally, some differences could be attributed to substantial variations on sample sizes across studies. In FCS, presence of a female traditional birth attendant (TBA) or community health worker (CHW) increased the possibility of receiving SBA. As demonstrated by several other resource-constraint settings (e.g. Kenya and Uganda), mainstreaming TBA or CHW into formal primary care system can be a feasible option to improving access to MNH care in FCS as well [44, 45].

Facility-based delivery was higher than SBA usage, and highest in the Palestinian Territories. Literature indicates that the Palestine Territories, despite fragility and ongoing conflict has a comparatively higher rate of dependence on skilled professionals for maternal care, even in refugee camps, though quality of care is a concern [34, 35]. Small geographical size of the territories likely contributes to higher SBA usage [37]. Elsewhere, dependence on TBAs was considerable, and generally attributed to inadequate availability of professional care and potential lack of awareness [31]. Over-reliance on TBAs is commonly reported in FCS globally due to demand- and supply-side barriers to usage of professional services [36, 37].

Usage of newborn services was mixed. Usage of public facilities was higher than for private facilities in these FCS [30], a trend recognised in FCS globally (e.g. Zimbabwe, Somalia) [7, 38, 39]. While findings were mixed on initiation of early breastfeeding within an hour of birth, no study found timely care-seeking for neonatal health concerns. Several women reported using traditional healers instead, as reported in other FCS [7, 38‐43].

It is essential to highlight the fundamental inequity found in MNH services usage in the studies included. Both demand- and supply-side factors favoured wealthier women. For example, MNH services usage was higher among women who were wealthier and in geographically-accessible areas. It is likely these women had more knowledge, income, and/or available services encouraging greater usage. Inequity in MNH services access is found in both FCS and non-FCS (e.g. Nigeria, Uganda) [41, 42] as social programmes tend to favour advantaged populations through existing structures and practices in coverage and implementation [42]. However, FCS must address a relatively stronger vicious circle of inequity due to weak governance and policy paralysis, which augment these inequities [46, 47].

To address the barriers and inequities discussed, FCS require more support than do non-FCS. However, international donor presence does not necessarily streamline health policy-making in FCS [2, 3]. For example, though targeted policies and strategies for vulnerable groups were planned by donors, often no commensurate improvement in living and health standards is visible, due to issues such as weak aid coordination, planning and institutional support. [2‐4] Authors propose adapting targeted policy approaches to improve coordination of aid and planning. Specific demand-side initiatives are needed to address socio-cultural barriers and women’s financial access to healthcare in FCS. Given the often limited finances available to women in FCS, policy-level action is necessary to reduce demands for informal payments [26, 31]. Supply-side issues with availability of community-based workers and transportation services were emerging themes that require additional research.

This review is limited by the studies available. Though incorporating a vast literature, this review included only peer-reviewed research articles with a minimum level of methodological quality, thus considerable gaps remain. Authors adhered to the FCS classification used by the World Bank, which may have omitted some potential fragile countries in Asia or the Middle-East. Additionally, authors did not analyse sub-national fragility and therefore omitted non-FCS with higher burdens of maternal and neonatal ill-health (e.g. India) [47]. Caution should be used in interpreting findings, as studies included were primarily non-generalisable.

Despite limitations, this review is relevant for contributing analysis of the evidence on MNH service-usage in FCS and potentially increasing policy attention for this under-researched topic. As this review covers the relatively under-studied factors associated with MNH and service-usage in Asian FCS, inclusion of both qualitative and quantitative data strengthened potential triangulation.