Factors associated with antenatal and delivery care in Sudan: analysis of the 2010 Sudan household survey


The present study demonstrated the association between a range of factors and attending
ANC and place of delivery. Factors found to be associated with both attending ANC
and institutional delivery were higher educational attainment, higher household wealth
and low parity.

Our study highlighted an association between maternal education and attending ANC
and institutional deliveries, findings that are consistent with the results of previous
studies 2], 3], 5], 6], 10]. With few exceptions, all studies in this field found a strong and dose-dependent
positive effect of educational level on use of maternal services 3].

Several pathways have been suggested through which maternal education might affect
health-care use. For example, highly educated women are more likely to be aware about
the importance of health services and more able to select the most appropriate service
for their needs 3], 10]. In addition, educated women have more opportunities to enter into the labour market,
and therefore have access to financial resources and more decision-making power 3], 10].

Although interventions targeting female education may not have a short-term effect
on enhancing service use, education should still be considered as a key intervention
to promote the use of ANC services, not only because it will increase women’s awareness,
but it will also lead to increased empowerment of women and may improve their access
to financial resources throughout their adulthood.

Our study showed that there was an increased likelihood of attending ANC and having
an institutional delivery associated with increased household wealth. The role of
household economic status on health service use has been reported in previous studies
3], 6], 7], 10], with women from households with a high wealth index being more likely to afford
health services than those of a lower wealth index 10]. Although some of Sudan’s maternal health services are provided free of charge at
government health facilities, additional costs of care-seeking are not covered, such
as costs of transportation, supplies and the opportunity costs of travel and waiting
time. This is especially relevant to institutional deliveries, where women are usually
accompanied by other family members, further increasing care-seeking costs. Women
from poor households may struggle to cover these additional costs, and are therefore
less likely to seek maternal health services at an institutional level 3].

In contrast, home deliveries supervised by traditional birth attendants (TBAs) are
usually perceived as affordable, as transportation costs are not necessary and payment
is usually negotiable in terms of amount and timing, and can be in kind 3]. Economic status, when it becomes a determinant of health care use, implies access
to health care is inequitable 13]. Coverage by health insurance to meet the cost of those services not provided free
of charge, and expanding health services as near as possible to the target population
are two measures that can be implemented to improve access for underprivileged populations
and enhance maternal service use.

The association between high parity and low use of maternal health services observed
in our study has been reported in previous studies 2], 10], which found that women with high parity tend to rely on their experience from previous
pregnancies and do not feel the need for antenatal checks, believing they already
know what to expect during pregnancy and childbirth. We observed a similar parity
effect for the place of delivery, with our results showing that multi-parity was associated
with home delivery. Other studies have reported similar results, with higher levels
of service use reported for the first and lower order births when compared with higher
order births 3], 7]. Unfortunate experiences in hospitals, quicker childbirth in multiparous women or
having had an uncomplicated first delivery might explain why some multiparous women
deliver at home. In contrast, as the first birth is known to be more difficult and
a woman usually has no previous experience of delivery, they might be more likely
to seek professional help and advice. In addition, women with several small children
may experience greater difficulty in attending facilities for both ANC and child birth,
because of the need to arrange child care 3], 7], 10].

Our findings emphasise the importance of raising the awareness among women about the
risks associated with pregnancy and childbirth, and the importance of both ANC services
and institutional delivery. Our findings also suggest that provision of family-friendly
services as close as possible to the target population is necessary.

Our study also found that area of residence (urban or rural) was associated with institutional
delivery, but not with ANC use. This may be explained by the inaccessibility of institutional
delivery services in rural areas. In many rural areas in Sudan, primary health centres
provide ANC but are not equipped for delivery services. In these areas, women depend
on midwives to perform home deliveries. In areas where primary health centres are
not available, midwives visit women at their homes to provide both ANC and child delivery
services. Even when an institutional delivery is planned at a nearby urban area, additional
challenges are presented by factors such as lack of or difficulty arranging transportation,
especially if need arises at an inconvenient time.

In contrast, similar studies from other countries reported an advantage for women
living in urban areas over women in rural areas with regard to ANC use, attributed
to different service and social environments 2], 4], 10]. This inconsistency in results may indicate that in rural Sudan, free ANC services
may lead to higher use of these services. This is despite the fact that in Sudan,
urban women were found to have better educational attainment indicators than their
rural counterparts 8]. This emphasises the importance of the availability of accessible, affordable health
services in encouraging women to use ANC services.

The effect of the enabling factor (ANC use) was tested by the probability of having
an institutional delivery. The results of the present study indicated that women who
attended ANC services had an increased likelihood of having an institutional delivery.
This is consistent with results of previous studies 5], 7], 10]. ANC is an opportunity for health workers to promote a specific place of delivery
or give women information about the status of their pregnancy; which in turn informs
their decisions on where to deliver. The association between ANC use and institutional
delivery might be a reflection of the availability of and access to services, as women
who reside closer to facilities are more likely to use ANC and delivery services 3]. In addition, ANC attendance can be a marker of familiarity in interacting with the
health system and with the health facility 3], 5], with women who use ANC services being more likely to use facilities for delivery.

The presence of complications during the index pregnancy was included in our study
to represent need factors. Our results showed that women who had encountered serious
complications during their pregnancy were more likely to have an institutional delivery.
This is consistent with the findings of previous studies in countries where deliveries
attended by skilled personnel are low 5]. The factors associated with institutional delivery suggest that women opted for
health facility delivery primarily when problems were encountered during pregnancy.
The problems experienced during the index pregnancy might have made these women seek
health services during pregnancy; with health workers subsequently recommending a
health facility delivery 3].

This indicates that the complications encountered are translated into perceived need,
and that women judged these complications to be of sufficient importance and magnitude
to seek professional help. This in turn depends on women’s knowledge of danger signs
and on their beliefs about the causes of these signs 13], again emphasising the importance of raising the awareness of women through appropriate
community-based and intensive behavioural communication strategies. These strategies
should reinforce women’s perception of danger signs, direct their decision-making
towards appropriate action and finally, ensure that this knowledge will prompt the
appropriate action 14], 15].

A major limitation of the present study was the lack of data on enabling factors such
as the availability and accessibility of health services. The SHHS provided data related
to service users, whereas data about the availability, accessibility and quality of
health services were lacking. This made it difficult to test the effect of the full
range of factors and their interactions.

Another limitation is the cross-sectional design of the present study, as it restricts
the interpretation of the causality of factors associated with using maternal health
services. Recall bias may be a further limitation, but its effect was minimised by
including events occurring during the two years preceding the survey.

The main strength of the present study is the large, nationally representative sample
which contributes to the validity of our results.