University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA LEGON DETERMINANTS OF MATERNAL HEALTH CARE SERVICES UTILIZATION IN SIERRA LEONE BETWEEN 2009 AND 2013 BY FRANCIS JOHN YAMBA (10639101) THIS THESIS/DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. JULY 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I declare that this thesis entitled “Determinants of maternal health care services utilization in Sierra Leone between 2009 and 2013” has been composed wholly by myself under the guidance and supervision of Professor Richard M.K Adanu. Except where stated otherwise by reference or acknowledgement, this work is entirely my own. This work has not been submitted in whole or in part, for any other degree or professional qualification. _________________________ Date _________________________ Francis John Yamba Master of Public Health Candidate ___________________________ Date_________________________ Prof Richard M K Adanu Academic Supervisor i University of Ghana http://ugspace.ug.edu.gh DEDICATION This thesis is dedicated to the Almighty God for being the source of my strength throughout this course, to my mother; Janet Maotta Yamba, my wife; Pheabean Yamba and daughter; Lovette Maotta Yamba for their undying love. I also wish to dedicate this thesis to the memory of my late father; Simeon Brima Yamba, Who always had confidence in me. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS First and foremost, I have to thank my sponsor; the department of Reproductive Health and Research (RHR) of the World Health Organization, particularly Professor Anna Thorson and Dr. Philippe Gaillard, for providing the financial supports throughout this course. I also owe much to my dear Lecturers of the School of Public Health, especially my abled, dedicated and meticulous supervisor, Professor Richard Adanu, all of who contributed greatly and in various ways towards achieving this great success. By no means could I fail to acknowledge the effort of Professor Eusebius Small, Lecturer of The University of Texas at Arlington, whose technical input and advice throughout this course is worth commending and remembering. My appreciation goes to Mrs. Abena Engmann, Ms. Emefa Judith Modey, Mr Chris B. Guure, all well-wishers, and contributors as well, whose names could not be mentioned in this piece. May God bless you all! iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT BACKGROUND: Sierra Leone has one of the worst maternal health indices among other countries, and it is also one of the countries with the lowest human development index. Majority of the causes of maternal morbidity and mortality can be prevented by means of utilization of adequate antenatal care, institutional delivery and skilled birth attendants. However, utilization of Maternal Health Care (MHC) services is generally low in the country. There is an alarming shortage of skilled Health Care Workers (HCW) and limited number of Health Care Facilities (HCF). OBJECTIVE: To identify the factors that influenced the utilization of MCH Services during the five years period preceding the 2013 Sierra Leone Demographic and Health Survey (SLDHS). METHOD: Data on the most recent pregnancy during the five years period preceding the 2013 Demographic and Health Surveys (DHS) were used. Outcome measures were Antenatal Care and Delivery Care. Chi square test and Logistic regression models were used to determine the relationships between key socio-demographic factors and outcome measures. iv University of Ghana http://ugspace.ug.edu.gh RESULTS: Antenatal Care Almost all pregnant women (94%) in Sierra Leone received antenatal care (ANC) from skilled providers (doctor, nurse, midwife, or MCH aide) during the five years period preceding the 2013 SLDHS; most commonly from a nurse/midwife (58%), followed by MCH Aide (34%). The government health facilities were the commonest place of ANC for the majority (95%) of the pregnant women. Almost all of the women (98%) made at least one ANC visit, whilst 89% made four (4) or more visits during their pregnancy. About 93% of women took iron tablets or syrup during pregnancy and 89% of the women were informed about signs of pregnancy complications during ANC visit. Ninety five percent of women’s most recent births were protected against neonatal tetanus whilst only 75% took antimalarial prophylaxis. Place of residence, age and religion of the respondents were found to be significant determinants of ANC services utilization during the five years period preceding the 2013 SLDHS. Almost all (99%) of the women in the urban area had ANC at a health facility compared to those in the rural area (98%). Delivery Care Only about 59% of deliveries occur in health facilities; mainly in government health facilities (57%). More than 2 in 5 births occur at home. Nearly 6 in 10 deliveries were assisted by skilled providers. v University of Ghana http://ugspace.ug.edu.gh Women whose marital status was described as separated/divorced/widowed were more likely to give birth in a health facility. Those women who practice traditional/other religion were less likely to give birth in a health facility. Similarly, women who had ANC and also those from households with high wealth index were most likely to have their births attended by a skilled provider. CONCLUSIONS: The utilization of Delivery Care services by the women was low, despite the high utilization of the ANC services. Home delivery is still a serious problem in Sierra Leone because a greater proportion of the women gave birth in homes in the hands of unskilled birth attendants. The utilization of MHC services was influenced by several socio-demographic characteristics of the women such as Age, Region, Religion, Household Wealth Index, Marital Status, Place of Residence and Parity. vi University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENTS ........................................................................................................... iii ABSTRACT ................................................................................................................................... iv LIST OF TABLES .......................................................................................................................... x LIST OF FIGURES ....................................................................................................................... xi LIST OF ABBREVIATIONS ....................................................................................................... xii DEFINITION OF TERMS .......................................................................................................... xiii CHAPTER ONE ........................................................................................................................... 14 1.1 INTRODUCTION ............................................................................................................... 14 1.2 Problem statement ............................................................................................................... 17 1.3 Conceptual framework of the study .................................................................................... 18 1.4 Justification ......................................................................................................................... 20 1.5 Objectives ............................................................................................................................ 21 1.5.1General Objectives ........................................................................................................ 21 1.5.2 Specific Objectives ....................................................................................................... 21 1.6 Research Questions ............................................................................................................. 21 CHAPTER TWO .......................................................................................................................... 22 2.0 LITERATURE REVIEW .................................................................................................... 22 2.1 Strategy for Literature Search ............................................................................................. 22 2.2 Concept of Maternal Health Care (MHC) ........................................................................... 23 2.3 Status of maternal health care in Sierra Leone .................................................................... 24 2.4 Components of Maternal Health Care Services .................................................................. 26 2.4.1 Antenatal Care (ANC) .................................................................................................. 26 2.4.2 Delivery care ................................................................................................................. 29 2.5 Determinants of maternal health care services utilization .................................................. 30 CHAPTER THREE ...................................................................................................................... 34 3.0 METHODOLOGY .............................................................................................................. 34 3.1 Country Profile .................................................................................................................... 34 3.2 Source of data ...................................................................................................................... 36 3.3 Demographic and Health Survey Study Design .................................................................. 36 vii University of Ghana http://ugspace.ug.edu.gh 3.4 Data collection tools ............................................................................................................ 36 3.4.1 Inclusion Criteria .......................................................................................................... 37 3.4.2 Exclusion Criteria ......................................................................................................... 37 3.5 Description and measurement of variables ......................................................................... 38 3.5.1 Dependent variables ..................................................................................................... 38 3.5.2 Independent variables ................................................................................................... 38 3.6 Derivation, recoding, labeling and renaming of the outcome variables.............................. 40 3.7 Data Analysis and presentation ........................................................................................... 41 3.8 Data limitation ..................................................................................................................... 42 3.9 Ethical consideration ........................................................................................................... 42 CHAPTER FOUR ......................................................................................................................... 43 4.0 RESULTS............................................................................................................................ 43 4.1 Characteristics of Women Who gave birth during the five year period preceding the 2013 SLDHS ...................................................................................................................................... 43 4.2 Antenatal Care ..................................................................................................................... 46 4.2.1 Place of Antenatal Care ................................................................................................ 46 4.2.2 Provider of Antenatal Care ........................................................................................... 46 4.2.3 Number of Antenatal Care Visits ................................................................................. 47 4. 3 Delivery care ...................................................................................................................... 48 4.3.1 Place of delivery ........................................................................................................... 48 4.3.2 Delivery attendant ......................................................................................................... 49 4.4 Determinants of utilization of Antenatal care ..................................................................... 50 4.4.1 Bivariate association for place of antenatal care .......................................................... 50 4.4.2 Multivariate logistic regression analysis for place of antenatal care ............................ 51 4.4.3 Bivariate association for provider of antenatal care ..................................................... 53 4.4.4 Multivariate logistic regression analysis for provider of antenatal care ....................... 54 4.4.5 Bivariate association and Multivariate logistic regression analysis number of antenatal care visits ............................................................................................................................... 56 4.5 Determinants of utilization of Delivery care ....................................................................... 59 4.5.1 Bivariate association for place of delivery ................................................................... 59 4.5.2 Multivariate logistic regression analysis for place of delivery ..................................... 60 4.5.3 Bivariate association for delivery attendant ................................................................. 62 viii University of Ghana http://ugspace.ug.edu.gh 4.5.4 Multivariate logistic regression analysis for delivery attendant ................................... 64 CHAPTER FIVE .......................................................................................................................... 66 5.0 DISCUSSION ..................................................................................................................... 66 5.1 Introduction ......................................................................................................................... 66 5.2 Determinants of utilization of ANC services ...................................................................... 66 5.3 Determinant of utilization of delivery care services ........................................................... 70 CHAPTER SIX ............................................................................................................................. 73 6.1 CONCLUSION AND RECOMMENDATIONS ................................................................ 73 REFERENCES ............................................................................................................................. 76 APPENDICES ........................................................................................................................... 81 Appendix A: Sample design for the 2013 sierra Leon demographic and health survey……81 Appendix B: 2013 Sierra Leone demographic and health survey woman’s questionnaire...91 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Comparison between Focused Antenatal Care (FANC) and the recent 2016 WHO ANC model(WHO, 2016) ...................................................................................................................... 29 Table 2: Socio-demographic data of women who gave birth during the five (5) year preceding the 2013 SLDHS (N= 12,352) ...................................................................................................... 45 Table 3: Classification of respondents based on number of ANC visits ...................................... 48 Table 4: Proportion of Sierra Leonean antenatal attendants benefiting from different aspects of routine ANC, 2009-2013 .............................................................................................................. 48 Table 5: Socio-demographic Characteristics of respondents from the 2013 Sierra Leone Demographic and health survey and association with type of place of antenatal care (N=8,272) 50 Table 6: Crude and Adjusted odds ratios showing association between type of place of antenatal care from the 2013 SLDHS and selected socio-demographic characteristics .............................. 52 Table 7: Association between the type of provider of antenatal care from then 2013 SLDHS and socio-demographic characteristics ................................................................................................ 53 Table 8: Crude and adjusted odd ratios showing association between ANC provider and socio- demographic characteristics .......................................................................................................... 55 Table 9: Association between the independent variables and the number of antenatal visits 2009- 2013 (N=8,478) ............................................................................................................................. 57 Table 10: Crude and Adjusted Odds Ratio showing association between the socio-demographic characteristics and number of ANC visits from the 2013 Sierra Leone Demographic and health survey ............................................................................................................................................ 58 Table 11: Socio-demographic Characteristics of delivery care users from the 2013 Sierra Leone Demographic and health survey and association with place of delivery (N=8,446) .................... 59 Table 12: Crude and Adjusted Odds Ratio showing association between place of delivery from the 2013 Sierra Leone Demographic and health survey and background characteristics............. 61 Table 13: Socio-demographic Characteristics of delivery care users from the 2013 Sierra Leone Demographic and health survey and association with category of delivery attendant (N=8,446) 63 Table 14: Crude and Adjusted Odds Ratio showing association between category of delivery attendant from the 2013 Sierra Leone Demographic and health survey and background characteristics ................................................................................................................................ 64 x University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework of the determinants of MHC Services utilization ................... 19 Figure 2: Map of Sierra Leone showing the regions and districts ................................................ 34 Figure 3: Place of antenatal care for Sierra Leonean women, 2009-2013 (N=8272) ................... 46 Figure 4: Provider for antenatal care to Sierra Leonean women, 2009-2013 (N=8429) .............. 47 Figure 5: Place of delivery for Sierra Leonean women, 2009-2013 ............................................. 49 xi University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ANC Antenatal Care DHS Demographic and Health Survey FANC Focused Antenatal Care MDGs Millennium Development Goals MHC Maternal Health Care MMR Maternal Mortality Ratio PoD Place of Delivery SBA Skilled Birth Attendant SDGs Sustainable Development Goals UBA Unskilled Birth Attendant UNDP United Nation Development Programme UNFPA United Nations Population Fund UNICEF U nited Nations Children’s Fund WHO World health organization WRA Women of Reproductive Age xii University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS ANTENATAL CARE: Antenatal care (ANC) can be defined as the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy. DELIVERY CARE: this can be defined as the care provided by skilled attendant to pregnant women during childbirth. DIRECT OBSTETRIC DEATH: Maternal deaths resulting from obstetric complications of the pregnant state, from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of these. INDIRECT OBSTETRIC DEATH: Maternal death resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. MATERNAL MORTALITY OR MATERNAL DEATH: is 'the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. MATERNAL MORTALITY RATIO (MMR): The number of maternal deaths occurring in a given year per 100,000 live births during the same period. MATERNAL MORTALITY RATE: The number of maternal deaths in a given period per 100,000 women of reproductive age. SKILLED BIRTH ATTENDANCE: The process by which a woman is provided with adequate care during labour, delivery and the early postpartum period. SKILLED BIRTH ATTENDANT: An accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.1 INTRODUCTION Maternal health, according to the World Health Organization, refers to “women’s health throughout pregnancy, delivery, and the postpartum period”. Maternal Health entails the health care aspects of family planning, preconception, antenatal, and postnatal care; all of which are aimed at reducing maternal morbidity and mortality. Maternal Health (MH) has become the most significant determinant of global, regional, national and local wellbeing (WHO, 2006). According to the World Health Organization (WHO), in 2013 about 289, 000 women died of pregnancy related death worldwide. Developing countries contributed 99% to these deaths; Sub- Saharan Africa region alone contributed 62%. The Maternal Mortality Ratio (MMR) in developing regions was 230 per 100,000 live births, whilst that for the developed regions was 16 per 100,000 live births. SSA region had the highest regional MMR of 510 per 100,000 live births. At country level, Sierra Leone had the highest MMR of 1100 per 100,000 live births (United Nations Development Programme (UNDP), 2016). Deaths related to pregnancy and childbirth claim a mother’s life every minute of every day. About eight(8) out of every ten(10) of these deaths are preventable(Gayle et al., 2010). From the result of the global, regional and sub-regional estimates of the causes of maternal death that occurred from 2003 to 2009 in one hundred and fifteen (115) countries analysed by the World Health Organization (WHO), over seventy percent (70%) of those deaths were due to direct obstetric causes ( such as haemorrhages and hypertensive disorders). The remaining thirty 14 University of Ghana http://ugspace.ug.edu.gh percent (30%) were due to Indirect obstetric causes and other causes such as HIV/AIDS, infection, cardiovascular diseases, etc. (Say et al., 2006). The global MMR dropped to 216/100 000 live births over 25 years period (from 1990 to 2015). Sierra Leone also managed to reduce its MMR from 2,630/100,000 live births in 1990 to 1,360/100,000 live births in 2015. However, this reduction was far from achieving the target of the MDG 5. The MMR of Sierra Leone is still among the highest in the world (Assaf & Winter, 2015). Reducing maternal mortality has been a common goal to governments and several international organizations. According to Amnesty International, maternal death is a human rights issue. The organization believes that preventable maternal death occurs as a result of depriving women of their essential human right to better health care. Therefore, failure to make available the appropriate Maternal Health Care (MHC) services to mothers during pregnancy and delivery can be considered a violation of their rights to life, health, equality and non-discrimination(Welfare & Health, 2010). Several steps have being taken by governments and international organizations at regional and continental levels in order to reduce or eliminate preventable maternal deaths. For instance, the 2009 African Union (AU) campaign titled “Accelerated Reduction of Maternal Mortality in Africa (CARMMA)” brought the attention of the entire Africa region to this challenge. People were trained to advocate for policies that will improve maternal health. CARMMA was adapted from the Maputo Plan of Action (Maputo PoA) which was adopted in 2016 by the AU. The main aim of Maputo PoA was to ensure that Africa achieves access to universal comprehensive sexual and reproductive health by 2015. 15 University of Ghana http://ugspace.ug.edu.gh The July 2010 AU Summit theme was “Maternal, Child and Infant Health and Development in Africa”. It was agreed without objection that more investments should be made in Maternal and Child Health (MCH). Similarly, in April 2010, another global move was made by the then Secretary-General of the United Nation requesting leaders to pay more attention on the health of women and children (United Nations Development Programme (UNDP), 2016). The Sierra Leone government has also placed some importance on MHC by incorporating it into the country's development agenda plan. The government launched a five-year Poverty Reduction Strategy Paper called "Agenda for Change (2008-2012)". Priority was given to the reduction of maternal and child mortality. The government also implemented Free Health Care services for pregnant women, breastfeeding mothers and children less than five years of age (UNFPA, 2013). The utilization of MHC services in Sierra Leone is influenced by factors such as traditional and religious beliefs, acceptability of interventions, perceptions on quality of care, socio-economic status of the women, education, rural/urban residence, employment status, relationship status of the women, knowledge about danger signs in pregnancy, distance from health facilities, and parity (UNFPA, 2013). This study was therefore carried out in order to find out the various determinants of utilization MHC services in Sierra Leone during the five years period preceding the 2013 Sierra Leone Demographic and Health Survey (SLDHS). This study focused on the Antenatal (ANC) and Delivery care. 16 University of Ghana http://ugspace.ug.edu.gh 1.2 Problem statement Getting pregnant and giving birth to a child is one of the most dangerous risks a woman can take in Sierra Leone. For approximately every 73 live births in 2015, one woman dies; mainly as a result of preventable maternal causes. In 2015 alone the estimated maternal death was 3,100. Majority of the women in Sierra Leone reside in rural areas; where access to health care during pregnancy is difficult. Most of them who will need caesarean sections will not receive it because of the fact that many of the birth attendants are actually unskilled and do not know how to perform a caesarean section or to carry out other procedures that can help the mothers survive. The health of a mother and the newborn are closely linked. Sierra Leone’s neonatal mortality rate in 2015 was 35 per 1,000 live births; which was among the highest in the world. There are also large number of adolescent pregnancies, which have a direct effect on maternal mortality(Survey, 2013). Sierra Leone is also one of the poorest countries in the world. The country was ranked one hundred and seventy nine (179) out of the one hundred and eighty eight (188) countries included in the 2015 United Nations Human Development Report(United Nations Development Programme (UNDP), 2016). The decade-long civil conflict that raged from 1991 to 2002 wrecked the infrastructure, human capacity and the entire health systems in the country. During the post-conflict period, unsustainable practices and corruption became embedded as the norm. Maternal health – an important indicator for determining the wellbeing of a nation was not given the attention it deserves. 17 University of Ghana http://ugspace.ug.edu.gh The MDG 5 which was aimed at Improving maternal health through reduction of the year 1990 MMR by three-quarters (MDG 5A) and achieving universal access to reproductive health (MDG 5B), was not achieved by Sierra Leone. The country had the highest MMR at 1,360 deaths per 100,000 live births (WHO, UNICEF, UNFPA, World_Bank_Group, & UNPD, 2015). Underneath these statistics lies the pain of human tragedy for us all; and especially for thousands of families who have lost their love ones as a result of pregnancy and child birth. The Ebola epidemic in 2014 also significantly affected maternal and neonatal health services. During the outbreak there was a general fear of infection among both health care workers and patients. This also resulted to a low uptake of MHC services in the entire country (UNICEF, 2014) There was an already existing problem of shortage of health personnel in Sierra Leone even before the outbreak. This problem was exacerbated by the Ebola outbreak which claimed the lives of so many healthcare workers. An estimated thirty percent (30%) of those healthcare workers were working in Maternal and Child Health Units. The Ebola outbreak also made many hospitals to stop providing services to the people, including pregnant women (Brolin Ribacke et al., 2016). Given this gloomy picture about this problem, there is much more needed to be done in order to salvage the population exposed to the risk of preventable maternal death, which should be of grave concern to everyone. This is more so as it impinges on the country’s general development. 1.3 Conceptual framework of the study This framework was adapted from Andersen and Newman’s behavioural model of the determinants of health service utilization. 18 University of Ghana http://ugspace.ug.edu.gh The framework shows the relationship between the independent (predictor) variables considered in this study and how they affect the outcome variables. Figure 1: Conceptual Framework of the determinants of MHC Services utilization Enabling Factors • Household wealth index • Place of residence MHC Services • Region • Antenatal Predisposing factors • Care Age • Religion • Delivery • Education Care • Marital Status • Parity Need based Factors • Expected benefits/need This model was chosen for this study because it is in line with the study objectives. According to the model, some characteristic factors can contribute to, or determine the uptake of health care services by an individual. These characteristic factors are considered the independent variables in this study. They are categorized into three (3): 1. Predisposing factors; 2. Enabling factors and 3. Need based factors. The dependent (or outcome) variable are the various MHC Services (Antenatal care and Delivery care services) that are utilized. 19 University of Ghana http://ugspace.ug.edu.gh The predisposing factors are those socio-demographic characteristics that might cause some people to utilize MHC Services more than others. These socio-demographic characteristics in this study includes: age, education, religion, marital status and parity. The enabling factors assume that some resources are needed by an individual in other to utilize health services. The enabling factors in this study include the household wealth index, place of residence, and region. The Need-based factor is considered the stimulus for the use of MHC Services. Only the Predisposing and Enabling factors are considered in this study. 1.4 Justification This study is justified on the following grounds: Foremost, maternal death is a very serious issue of public health concern, especially for developing countries where the uptake of MHC services is low. ANC, delivery and postpartum care are three most important interventions proposed by the WHO in order to reduce maternal death. Identifying those factors influencing the utilization these services would have meaningful effect on the reduction of the high MMR in countries like Sierra Leone. Also, findings from this study may help in the implementation of sexual and reproductive health programmes in Sierra Leone. Next, findings from this study may be of value to for the country as a whole and for decision makers in planning, implementing and evaluating various interventions related to reduction of maternal mortality and to achieve the targets of goal 3 of the Sustainable Development Goals (SDG3) in 2030. Finally, this piece may benefit the society, particularly Women in the Reproductive Age (WRA) to better utilize MHC Services which will improved their health status and wellbeing. 20 University of Ghana http://ugspace.ug.edu.gh 1.5 Objectives 1.5.1General Objectives To identify the factors that influenced the utilization of MCH Services during the five years period preceding the 2013 SLDHS. 1.5.2 Specific Objectives i. To estimate the proportion of women that utilizes the various MHC Services. ii. To assess the main determinants of the utilization of MHCS iii. To examine the pattern of uptake of MHCS. iv. To determine the level of utilization of Antenatal and Delivery Care services. 1.6 Research Questions i. What is the level of utilization of Antenatal and Delivery care services? ii. What factors determine the choice of place ANC among pregnant women? iii. Which socio-demographic factors influenced utilization of delivery services? iv. What is the proportion of women who received MHC services from skilled and unskilled providers? 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW This study is looking at the determinants of Maternal Health Care (MHC) services utilization in Sierra Leone during the five years period preceding the 2013 SLDHS. 2.1 Strategy for Literature Search Various secondary materials including research findings from different sources in the form of articles, journals, books, etc. is utilized in the process, more so, those having to do with maternal health care. Materials were got from the following data bases: PubMed, Google, Google scholar, Jstor, Research gate, Science direct, Elsevier and Scopus. Materials were also got from the websites of international organizations that deals with maternal health (E.g. WHO, UNFPA, UNDP, UNICEF, MEASURE dhs.com and USAID). In order to expand or narrow the search for the literature, different words were combined during the search for articles. 22 University of Ghana http://ugspace.ug.edu.gh Box1: Literature Search techniques “Maternity” or “Maternity care” or "Maternal health Care" or "maternal health" or "maternal health Care Services" or “Reproductive Health” or "antenatal care" or "prenatal care" or "obstetric care" “ Natal care” or "delivery care" or “ Intrapartum care” or "skilled birth attendant" or "institutional delivery" or “Home delivery” or "health facility" or "utilization of' " or “factors affecting" or "factors influencing" or "factors associated" or "factors associated with" or "determinants of" or "influence of" or "components of" or "women employment" or "household wealth Index” or "religion" or "parity" or "educational attainment" or “ Sierra Leone" or "Africa" or "sub-Saharan Africa" or “Demographic and Health Survey” or “ Maternal Mortality Rate” or “ Maternal Mortality ratio” or “Maternal Death” The available related literature was critically reviewed and presented with the aim of describing:  The concept of MHC;  Status of MHC in Sierra Leone;  Components of MHC services;  Determinants of utilization of MHC services. 2.2 Concept of Maternal Health Care (MHC) Motherhood is expected to be a good and fulfilling experience, but unfortunately it is a period that is however characterised by suffering, illness and even death (WHO 2017). Maternal health should not be taken as just a “women’s issue”. It concerns the wellbeing of everyone (including men, boys and girls) and the integrity of communities, societies and nations. Globally, maternal mortality is still high. An estimated 800 women die daily due to complications they develop during pregnancy, childbirth or postpartum period. In 2010 alone, 287 000 maternal deaths were reported. Almost all (99%) of these deaths occurred in developing countries. Majority of these deaths are preventable if adequate MHC Services are available, and are well utilized by the women(“Maternal mortality fact sheet,” 2015). 23 University of Ghana http://ugspace.ug.edu.gh It has been shown that the health of mothers and their babies are closely related. Therefore, to prevent maternal deaths there should be interventions that are effective and sustainable. Such interventions include provision of essential services such as quality ANC, skilled attendance at birth, emergency obstetric and newborn care, nutrition, and postpartum care (UNICEF, 2009). According to Addisse (2003), the main objective of a MHC program is to reduce maternal and child morbidity and mortality. Achieving this objective requires the following:  Provision of primary health care services.  Provision of Integrated MCH services more particularly in the rural settings.  Provision of MHC services at a cost compactible with the financial, material and human resources of the country.  Initiation, development and co-ordination of operational and other relevant research in Maternal and Child Health.  Preventing malnutrition and infection among mothers and children through health education and nutrition supplementation.  Promoting the use of immunisation, safe water and sanitation.  Efficient supply of, and promoting effective Family Planning programmes (Addisse, 2003). 2.3 Status of maternal health care in Sierra Leone In September 2000, MHC was set as a target by world leaders during the United Nation meeting on the development of the eight (8) MDGs. The MDG 5 was the maternal health goal. The MDG 5 (improve maternal health) has two targets set for every country: to reduce the MMR by three quarters (MDG 5A) and to achieve universal access to reproductive health (MDG 5B) by 2015. Although substantial progress on these targets has been made by some countries, many developing countries (Sierra Leone inclusive) did not achieve the needed reductions in 2015. Sierra Leone was very far from reaching the target (World Bank Group, 2016). 24 University of Ghana http://ugspace.ug.edu.gh Most maternal deaths are preventable because the interventions to prevent them from happening are well known. Some of these interventions include: Improved access to quality ANC during pregnancy, availability of skilled attendant during labour and delivery, and regular postpartum care. These interventions can decrease the maternal mortality and improve maternal health (“WHO Maternal mortality fact sheet,” 2015). Many initiatives have been implemented in Sierra Leone in order to improve maternal health. Some of these initiatives include the implementation of the National Population Policy 2009, the National Health Sector Strategic Plan 2010-2015, and the Free MCH Care Initiative. These challenges include: the 2014 Ebola epidemic, the civil war which ended in 2002, poverty, large rural population, poor infrastructure, high total fertility rates, low use of modern contraceptive, high level illiteracy level, low female education, traditional/cultural beliefs, limited number of health facilities, etc. (Statistics Sierra Leone (SSL) and ICF International 2014). The shortage of skilled health care providers (doctors, nurses or midwives, MCH Aide) is also alarming in the country. According to the WHO recommendation, a minimum of twenty three (23) skilled healthcare providers per 10,000 populations is expected for countries. Sierra Leone is having only two (2) skilled providers per 10,000 populations. In addition to this human resource challenge is a problem of access to quality health care, limited health expenditure, and issues of shortage of drug and medical supplies. Despite an overall increase in uptake of ANC as reported by the 2013 SLDHS reports compared to the 2008 Sierra Leone DHS reports, the country still have one of the worse maternal, neonatal and child health mortality indices. 25 University of Ghana http://ugspace.ug.edu.gh High proportion of pregnant women are still giving birth in homes with the assistance of unskilled birth attendance like TBAs, Traditional healers, and Community volunteers other(Sharkey et al., 2016). In the move towards the Sustainable Development Goals (SDGs) Sierra Leone has aligned with other countries that also have high maternal mortality in order bring down their MMR to 140 per 100,000 live births(MOHS, 2016). To achieve the Sustainable Development Goal 3 (SDG 3) target, the government has implemented key plans such as establishing an active Community Health Worker (CHW) programme to provide easy access to MHC services; provision of drugs like antimalarial; upgrading some health facilities to Basic Emergency Obstetric and Newborn care (BEmONC) centres; and strengthening the Maternal Death Surveillance and Response (MDSR)(MOHS, 2006). 2.4 Components of Maternal Health Care Services According to Annet (2004), the components of MCH services include: care during antenatal, delivery, and postpartum periods. This study focused on only antenatal and delivery care. 2.4.1 Antenatal Care (ANC) The relative contribution of ANC to maternal health is a serious debate. Complications arising during pregnancy and delivery are most of the time not predictable, and they often occur without warning signs. The debate is that the traditional use of ANC to identify “risk factors” (such as age, parity, height, etc.) attributed to poor maternal outcomes has little benefit because these “risk factors” are not the direct causes of the poor outcomes(Bloom, Lippeveld, & Wypij, 1999). 26 University of Ghana http://ugspace.ug.edu.gh However, several systematic reviews have shown an association between ANC during pregnancy and utilization of delivery care services. Utilization of ANC services can therefore lead to further utilization of additional maternal services like institutional delivery and seeking assistance for complications during delivery and postnatal period(Tsegay et al., 2013). The former World Health Organisation guidelines on ANC categorise pregnant women into two broad categories; those who needing only routine ANC (about 75% of pregnant women), and those with exiting health conditions or risk factors that require special care (25% of pregnant women). Four (4) or more ANC visits was recommended for the first category of women (with additional visits should conditions emerge which require special care). This is referred to as Focused Antenatal Care (FANC). The second category requires more ANC visits(Maternal & Neonatal Health (MNH), 2004) The guideline was also specific about the timing and contents of ANC visits based on the gestational age of the pregnancy. Clinical examinations and laboratory investigations that serve an immediate purpose and have been proven to be beneficial were done. Examples of such clinical examinations and laboratory investigations include fundal height determination, measurement of blood pressure, urinalysis for bacteriuria and proteinuria, and blood tests to detect syphilis, HIV and anaemia. Measurement of height and weight during ANC visits are no longer part of the routine check-up (Fife, 2010). FANC has been found to improve maternal outcomes by offering opportunity to detect and treat diseases earlier. For instance, control of high blood pressure or early detection of high blood pressure prevents eclampsia. This will lead to reduction of maternal mortality. 27 University of Ghana http://ugspace.ug.edu.gh Similarly, other interventions like detection and treatment of anaemia, giving antimalarial prophylaxis, and immunization against neonatal tetanus, are some of the services provided during ANC that can also result to improve maternal neonatal outcomes(Maternal & Neonatal Health (MNH), 2004). Activities that can be incorporated into ANC services include: providing counselling and education to pregnant women about their health and that of their children, giving then information about the danger signs of pregnancy, what to do if a pregnant woman develop complications, and where to get help, importance of good nutrition, benefits of child spacing, various options of family planning, benefits of breastfeeding to both mother and baby, etc. (Maternal & Neonatal Health (MNH), 2004). The current WHO guideline for ANC recommends a minimum of eight (8) ANC contacts. The first contact should take place in the first trimester (up to 12 weeks of gestation). Two (2) contacts should be scheduled in the second trimester (at 20 and 26 weeks of gestation), and five (2) contacts are required in the third trimester (at 30, 34, 36, 38 and 40 weeks). Table 1 below compares FANC and the current ANC model. The word “contact” is used in this new model instead of “visits”. “Contact” connotes an active link between a pregnant woman and a healthcare professional. Specific interventions are delivered at each contact. 28 University of Ghana http://ugspace.ug.edu.gh Table 1: Comparison between Focused Antenatal Care (FANC) and the recent 2016 WHO ANC model(WHO, 2016) Focused Antenatal Care (FANC) model 2016 WHO ANC model Trimesters Visits Duration of Contacts Duration of Pregnancy (in weeks) Pregnancy (in weeks) 1 8-12 1 Up to 12 First 2 24-26 2 20 3 26 Second 3 32 4 30 5 34 4 36-38 6 36 Third 7 38 8 40 2.4.2 Delivery care Delivery is considered safe when performed by Skilled Birth Attendant (SBA) (Bhandari & Dangal, 2013). The definition of a Skilled Birth attendant (SBA) is given as: “an accredited health professional (such as a midwife, doctor or nurse) who has been educated and trained to proficiency in skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in identification, management and referral of complications in women and newborns”(A joint WHO/UNFPA/UNICEF/World Bank statement, 1999). The lowest coverage of skilled delivery utilization is in Sub-Saharan Africa (SSA) region. It has been shown that only 45% of women receive services from SBAs in SSA. Access to SBA during childbirth can reduce the risk of preventable death or morbidity. Equipped SBA can prevent or manage life-threatening complications (such as heavy bleeding, Eclampsia, etc.) or refer a patient to a higher level of care(United Nations, 2013). 29 University of Ghana http://ugspace.ug.edu.gh The proportion of births attended by a SBA is one of the key indicators that was used for monitoring progress toward MDG 5. Some studies have shown an association between proportion of births attended by SBA and MMR. An increase in the proportion of birth attended by SBA will result in reduction in the MMR. A recent study in low and middle income countries revealed that an increase in the proportion of births attended by a SBA resulted in reduction in maternal mortality(Utz, Adegoke, Utz, Msuya, & Broek, 2014). 2.5 Determinants of maternal health care services utilization The following socio-demographic and economic factors, amongst others, are known determinants of the utilization of MHC services: age, place of residence, educational level, region, religion, marital status, parity and household wealth index (Chimankar & Sahoo, 2011). Muchie (2017), also identified the above factors as important determinants of utilization of MHC services in Ethiopia in his work titled “Quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia: A finding based on a demographic and health survey” (Muchie Kindie Fentahun, 2017). Age of the woman when pregnant is an important determinant of the use of MHC Services. Several studies have shown that younger women (less than 19 years) are less likely to attend ANC (Onyeonoro et al., 2014). A study carried out in Eritrea however found out that women of younger age were more likely to utilize antenatal care and skilled attendance at delivery compared to those in the older age groups (Kibreab Habtom, 2017). 30 University of Ghana http://ugspace.ug.edu.gh The wealth index is also an important determinant of utilization of MHC services, especially delivery care services. Women in the fourth and highest quintiles of the wealth index are found to be more likely to use MHC services than those belonging to the lower wealth quintile (Singh, Kumar, & Pranjali, 2014). It have being shown that the number of ANC visits increased as the wealth index increased, and there is also a clear pattern for the choice of place of delivery among women based on their wealth index quintile. Women in the higher economic strata and living in households with high wealth index are said to seek institutional delivery more than those in the lower household wealth index(Goel et al., 2015). Similarly, type of place of residence has been shown to influence the utilization MHC services. Women living in an urban community increases have increase odds of antenatal service utilization compared to those in the rural areas(Babalola & Fatusi, 2009). Women residing in urban areas are more likely to give birth in a health facility as compared to those living in some rural areas(Abor, Abekah-nkrumah, Sakyi, Adjasi, & Abor, 2011). Education level of the women is the single most important determinant. Educated women make greater use of MHCS than women with no education. This conclusion is supported by evidences from studies conducted in Uttarakhand (Chimankar & Sahoo, 2011), Ethiopia(Shegaw Mulu Tarekegn, Lieberman, & Giedraitis, 2014) , India(Singh et al., 2014) and Nigeria(Ayo Stephen & Odunayo Joshua, 2016). A study done in Peru to find out the role of women’s education on the utilization of MHC services show a strong positive association between education and the use of maternal health- 31 University of Ghana http://ugspace.ug.edu.gh care services. The strength of the association was found to be stronger for the utilization of delivery care than antenatal care (Elo, 2016). Religion has being found to be a determinant of utilization of MHC services in most developing countries in the world. A study carried out in Ghana identified religion of the respondent as a factor that affect the utilization of MHC services (Abor et al., 2011). In India, it was found out that there was less use of delivery care services among the Muslims women compared to those in other religious denominations (Singh et al., 2014). A study carried in Nigeria also revealed that women belonging to Islamic religion make less use of skilled ANC provider than those who belong Christianity (Ayo Stephen & Odunayo Joshua, 2016). Pandey et al. (2013), also found out that education, parity and wealth index, all have highly significant effects on the utilization of MHC services (Pandey, Dhakal, Karki, Poudel, & Pradham, 2013). Other studies have also shown that parity can influence utilization of MHC Services even more than age. Women who have given birth to only one child are more likely to utilize delivery care services. The likely reason for this is because of fear of developing complications during pregnancy and lack of delivery experience. Women with higher parity tends to deliver more at home due to self-confidence they may have developed(Shegaw Mulu Tarekegn et al., 2014). Higher parity women are found to be less likely to attend ANC or make their first ANC visit during the first trimester compared to the lower parity women. 32 University of Ghana http://ugspace.ug.edu.gh Currently married women are found to be more likely to go for ANC compared to those who are not married(Ochako, Fotso, Ikamari, & Khasakhala, 2011). 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 Country Profile Republic of Sierra Leone is a small country located in West Africa. It has an area of approximately 72,000 square kilometres (28,000 square miles). Sierra Leone is bordered by two countries; on the north-east it is bordered by the republic of Guinea and on the south-east by the republic of Liberia. The South-west border is formed by the Atlantic Ocean. Administratively, Sierra Leone can be split into four (4) regions: Western, Northern, Eastern and Southern regions. Each region is further split into districts; and each districts into chiefdoms. There are 14 districts and 149 chiefdoms in total. Figure 2: Map of Sierra Leone showing the regions and districts 34 University of Ghana http://ugspace.ug.edu.gh The capital of Sierra Leone is Freetown, located in the Western region. The country gained independence from Britain on 27 April 1961. There are fifteen (15) ethnic groups. The Mende, Temne, Limba, Madingo and Creole are the more popular tribes. The official language is English. The main religions are Christianity, Islam and Traditional. Majority of the people are Muslims. The population of Sierra Leone in 2015 was 7,076,119. Almost three-fourth of the people reside in rural areas. Forty one percent of the population are below age 15(Sierra Leone Statistics, 2015). Sierra Leone is classified by the United Nation as one of the least developed countries in the world. The 2016 United Nations Development Programme (UNDP) reports on Human Development scored Sierra Leone 0.420 on the Human Development Indices (HDI). This placed the country in the category of low human development with a position of 179 out of 188 countries and territories. These countries have a very low income per capita. Large proportions (70 %) of Sierra Leoneans have low socio-economic status. Life expectancy at birth for female and male are 51.9 and 50.8 respectively(United Nations Development Programme, 2016). The health indicators of the country are among the worse in the world. The infant mortality rate is 89 per 1,000 live births; under-five mortality rate is 120 per 1,000 live births and MMR 1,360 women per 100,000 births. Sierra Leone has three levels of health care delivery system. These levels are: (a) Peripheral health units (comprising of community health centres, community health posts, and MCH posts) provides services at community level; (b) district hospitals; and (c) regional or national hospitals. The providers of health care services are government, religious missions, local and international Non-Governmental Organisations and private individuals or groups. 35 University of Ghana http://ugspace.ug.edu.gh 3.2 Source of data This study involved analysis of secondary data obtained from the 2013 SLDHS which was carried out for the second time in the country. The first DHS was in 2008. 3.3 Demographic and Health Survey Study Design Summary of DHS design is discussed in this section. The DHS uses cross-sectional analytic design. DHS is a national representative survey intended to give reliable estimates for important variables for the entire country, urban and rural areas, the four regions and the fourteen districts. DHS utilizes two stage sample design in selecting samples. The first stage involves use of 2004 Sierra Leone General Population and Housing Census list for the enumeration areas (EAs) as a master sampling frame to select the primary sampling units or clusters. The next stage involves selecting households systematically from each cluster to ensure adequate number of completed individual interviews is obtained. The DHS design is attached as appendix A in this report. 3.4 Data collection tools The DHS used Standard questionnaires to collect data. The questionnaires are modified to fit specific system, situations and conditions of Sierra Leone. The three types of questionnaires used by DHS are “Household Questionnaire”, “Women’s Questionnaire”, and “Men’s Questionnaire”. 36 University of Ghana http://ugspace.ug.edu.gh Women of Reproductive Age (WRA), i.e. those whose age is from 15-49 years in the chosen household were qualified for individual interviews. Similarly, men 15-49 year old in the next household were also qualified for interview. For the purpose of this study only responses related to Maternal Health Care from the women’s questionnaire are used. The Women’s Questionnaire collected information from the WRA on the five year prior to the survey. Information on respondent’s Socio-demographic background, reproductive history, use of MHC services, vaccination for under five children, breastfeeding, infant nutrition, sexual activity, respondent’s partner, fertility preferences, awareness and knowledge about HIV/AIDS and other Sexually Transmitted Diseases (STDs) and other health related conditions were captured by the questionnaire. The women’s questionnaire is attached as appendix B in this report. The data utilized in this analysis is limited to responses on the most recent pregnancies during the five years before the 2013 SLDHS. 3.4.1 Inclusion Criteria: All women aged between 15-49 years who had at least one pregnancy within the five years before the 2013 SLDHS. 3.4.2 Exclusion Criteria: Women who were not pregnant within the five years before the 2013 SLDHS. Those with incomplete information on MHC services are also excluded. Those excluded from this study are 4,306 respondents who were not pregnant during the five years period preceding the survey. For antenatal care, additional 4,080 respondents who have incomplete information on place of antenatal care were further excluded. Similarly for ANC 37 University of Ghana http://ugspace.ug.edu.gh providers and number of ANC visits, additional 3,923 and 3,874 respondents respectively were excluded because of incomplete information. For Place of Delivery (PoD) and delivery assistant, 3,906 respondents were excluded because of incomplete information. 3.5 Description and measurement of variables 3.5.1 Dependent variables Two main variables were used for this study. They are: 1. Antenatal care (ANC) and 2. Delivery care. Utilization of ANC was measured using the following parameters a. Place of ANC; b. Provider of ANC and c. Number of ANC visits. Utilization of delivery care was measured using the parameters a. Place of delivery and b. Delivery attendants. 3.5.2 Independent variables Eight socio-demographic characteristics of the respondents were chosen as the independent variables in order to find out their effects on the utilization of MHC services. These variables include age, type of residence, education, parity, wealth index, current marital status, religion and region. 38 University of Ghana http://ugspace.ug.edu.gh The independent variables were chosen based on Andersen’s behavioral model of health service utilization. Some of the independent variables such as religion, parity, current marital status and education were re-categorized for analysis. The age variable was dealt with as a categorical variable of five-year age groups. Place of residence was analysed as a dichotomous variable of urban and rural. Based on the 2015 Sierra Leone total fertility rate of 4.5 births per woman parity was therefore analysed as a categorical variable. The categories were: 1. Category 1: those who have given birth to one child; 2. Category 2: those who have given birth to two to four children and 3. Category 3: those who have given birth to five or more children. Education was also analysed as a categorical variable. The categories are: no education; primary; secondary and higher. In the DHS secondary and higher education were separate categories but in this study secondary and higher levels were combined because the proportions of women in the higher education category are small. Region was analysed as a categorical variable: Western; Northern; Eastern and southern. Religion was also analysed as a categorical variable of no religion; Christianity; Islam; Traditional and other. Wealth index was measured as five categories (poorest, poor, middle, richer, richest). The wealth index assesses the economic status of the household. Household wealth index is the average score of some indicators of household ownership of items and facilities such as type of floor, 39 University of Ghana http://ugspace.ug.edu.gh piped water, toilet, electricity, radio, television and bicycle. The more the composite scores the higher the wealth index. Current Marital status was re-categorized as never married, married, cohabiting, separated, divorced and widowed. 3.6 Derivation, recoding, labeling and renaming of the outcome variables The place of antenatal care variable was derived from responses on place of prenatal care. The responses were recoded and labelled as: home, government hospital, government health centre, government health post, private hospital/clinic and others. Place of antenatal care was further categorised into non-health facility and health facility and renamed as type of place of antenatal care. The provider of antenatal care variable was derived from responses on who provided antenatal care to the respondents. The responses were recoded and labelled as: doctor, nurse or midwife, MCH Aide, TBA, community/village healer, other and no one. This variable was further categorized into unskilled providers and skilled providers and renamed as category of antenatal care provider. Number of antenatal visits variable was categorised and analyzed as: no antenatal care visit, 1-3 visits and 4 or more visits. Variable on place of delivery was derived from responses on the various place where respondents delivered. The responses were labelled as: home, government hospital, government health centre, government health post, private health facility and others. This variable further categorized into non-health facility and health facility and renamed as type of place of delivery. 40 University of Ghana http://ugspace.ug.edu.gh Similarly, the delivery attendant variable was derived from the various responses on attendant at delivery. The responses were labelled as: doctor, nurse or midwife, MCH Aide, TBA, relative/friend, other and no one. This was also further categorized into unskilled attendant and skilled attendants, and renamed as category of delivery assistants. All missing values and no responses (such as 9, 99 and 999) to the dependent and independent variables of interest were dropped. 3.7 Data Analysis and presentation Stata SE 14.1 is used for statistical analysis of the data. The data were declared a survey data using the svyset command. Descriptive statistics of the independent variables was done to determine the distribution of the respondents in terms of frequencies and percentages. This was presented in the form of socio- demographic summary table. Data on place of antenatal care, provider of ANC, PoD and delivery attendant were presented in the form of bar charts. Bivariate analysis was done to test for association using Pearson’s correlation coefficient and Fisher exact test(for variables with small proportion of responses) in order to find out the relationship between the independent and dependent variables. P-value of less than 0.05 (i.e. p<0.05) was set as the significance for the analysis. Logistic regression model was then applied to find out the strength of the association between the independent and dependent variables. Both simple and multiple logistic regression analysis were performed in order to get the crude and adjusted odd ratios respectively. The strength of the 41 University of Ghana http://ugspace.ug.edu.gh association for each independent variable was based on the odd ratios and the 95% confidence interval, while holding other factors constant. Presentations of the results were done in tabular and bar chart form. 3.8 Data limitation The data are affected by recall bias, non-response rate and inappropriate reporting of some questions relating to maternal health. Issues like why certain women are not using or are unable to use maternal health care services were not addressed. 3.9 Ethical consideration The 2013 SLDHS data was downloaded from the MEASURE DHS website for free. To access the data a written request was submitted to the DHS MACRO, and authorization to use the data for this study was then granted. 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.1 Characteristics of Women Who gave birth during the five year period preceding the 2013 SLDHS This chapter covers the findings of the determinant of MHC services utilization in Sierra Leone between 2009 and 2013 using the 2013 SLDHS data. The 2013 SLDHS covered a total of 16,658 women, and 12,352 (74.2%) of them had at least one pregnancy during the five (5) years period preceding the survey. This study analyzed only information on the most recent pregnancies. The independent variables include: Age, Place of residence, Education, Parity, Wealth Index, Religion, Region and Current marital status. Only data on respondents who have complete information on each dependent variable were analyzed. The age of the respondents ranged from 15-49 years. The mean age is 31±8.6 years. The highest number of children ever born (parity) is 16. The mean number of children is 4±2.5. About 36% of the respondents have given birth to 5 or more children (see table 2). From table 2, it can be seen that about 43.0% of the respondents are under age 30. Proportions in each age group decline with increasing age, reflecting the comparatively young age structure of the population in Sierra Leone. There were more respondents in the rural area than urban. Approximately 64.0% of the respondents were living in the rural area. 43 University of Ghana http://ugspace.ug.edu.gh The educational level indicate that majority (67.4%) of the respondents have no formal education. Nearly 38.2% of the households were classified as poor (poorest and poorer) based on the indices for the determining the wealth index of a household. The marital status of the respondents shows that most (78.9%) of them are married, whilst 10.4% have never married, 3.2% cohabiting, and 7.7% have separated, divorced or widowed. 44 University of Ghana http://ugspace.ug.edu.gh Table 2: Socio-demographic data of women who gave birth during the five (5) year preceding the 2013 SLDHS (N= 12,352) Number of respondents Socio-demographic n(%) 15-19 884(7.2) Age group 20-24 1,949(15.8) 25-29 2,482(20.1) 30-34 2,180(17.7) 35-39 2,228(18.0) 40-44 1,290(10.4) 45-49 1,339(10.8) place of Residence Urban 4,451(36.0) Rural 7,901(64.0) Highest No education 8,321(67.4) Educational level Primary 1,540(12.5) Secondary 2,191(17.7) Higher 300(2.4) Parity 1 2,462(19.9) 2-4 5,577(45.2) 5+ 4,313(34.9) Wealth Index Poorest 2,486(20.2) Poorer 2,237(18.1) Middle 2,373(19.2) Richer 2,879(23.3) Richest 2,377(19.2) Current marital Never married 1,283(10.4) Status Married 9,739(78.8) Cohabiting 382(3.1) Separated/Divorced/widowed 948(7.7) Religious No religion 39(0.3) denomination Christianity 2,525(20.4) Islam 9,756(79.0) Traditional/others 32(0.3) Region Western 1,762(14.3) Northern 4,708(38.1) Eastern 2,585(20.9) Southern 3,297(26.7) Total 12,352(100) 45 University of Ghana http://ugspace.ug.edu.gh 4.2 Antenatal Care 4.2.1 Place of Antenatal Care A total of 8,272 (67.0 %) respondents have complete information for the place of antenatal care. Figure 3 below shows that over 98 % of the respondents attended antenatal care at the health facilities 70 62.3 60 50 40 30 20 17.2 15.3 10 3.6 1.2 0.4 0 Home Gov Hospital Gov Health Gov Health post Private Others Centre Hospital/clinic Place of Antenatal Care Figure 3: Place of antenatal care for Sierra Leonean women, 2009-2013 (N=8272) 4.2.2 Provider of Antenatal Care A total of 8,429 ((68.2%) respondents have complete information on provider of antenatal care. The commonest provider of antenatal care was the nurse or midwife. This is followed by the Maternal and Child Health Aide (MCH Aide). See figure 4 below. Almost 94 % of ANC were provided by skilled providers (nurse or midwife, MCH Aide and doctor). 46 Percentage University of Ghana http://ugspace.ug.edu.gh 70 57.9 60 50 40 33.7 30 20 10 2 4.3 0.5 0.1 1.7 0 Provider of ANC Figure 4: Provider for antenatal care to Sierra Leonean women, 2009-2013 (N=8429) 4.2.3 Number of Antenatal Care Visits Data on the number of antenatal visits analyzed for the 8,478 (68.6 %) women who have complete information on number of antenatal care visits revealed that only 168 (2%) did not have any antenatal care during their pregnancy. Among those who had antenatal care (98%), about 7,543 (89%) had four or more visits during their pregnancy (table 3). Table 4 below shows the proportion of women who received the various aspects of routine antenatal care. The lowest coverage was in the areas of collection of urine sample for test for protein, and anti- malarial prophylaxis. Only 73.8% and 74.7% of women benefited from the urine test and anti- malarial prophylaxis respectively. 47 Percentage University of Ghana http://ugspace.ug.edu.gh Table 3: Classification of respondents based on number of ANC visits No. of visits Total n(%) No ANC 168(2.0) 1-3 767(9.0) 4+ 7,543(89.0) Total 8,478(100) Table 4: Proportion of Sierra Leonean antenatal attendants benefiting from different aspects of routine ANC, 2009-2013 ANC services Proportion of attendants receiving services (%) Blood pressure measurement 94.9 Anti-tetanus injection 94.8 Blood sample taken 90.2 Urine Sample taken 73.8 Iron supplementation 93.0 Told about pregnancy complications 89.2 Malaria prophylaxis 74.7 4. 3 Delivery care A total of 8,446 (68.4 %) respondents with complete information on delivery care was analyzed. 4.3.1 Place of delivery Figure 5 below shows the different place where the respondents gave birth between 2009- 2013. About 41% of the deliveries were done in homes, despite the high proportion of antenatal care uptake during pregnancy. Only 59 % of the deliveries were done in health facilities. The majority (57%) of the health facility deliveries were done in the government health facilities. 48 University of Ghana http://ugspace.ug.edu.gh 45 41.1 40 36.3 35 30 25 20 14 15 10 6.4 5 2 0.3 0 Home Gov Hospital Gov Health Gov Health Private health Others centre post facility Place of delivery Figure 5: Place of delivery for Sierra Leonean women, 2009-2013 4.3.2 Delivery attendant The nurse or midwife was the commonest attendant at delivery. The nurse or midwife attended about 48% of the deliveries. In total, only 64% of the deliveries were done by skilled birth attendants (Doctor, Nurse/midwife and MCH Aide). See figure 6 below. 60 50 47.8 40 32.1 30 20 14.2 10 2.5 3.3 0.02 0.3 0 Doctor Nurse/ Midwife MCH aide TBA Relative/ friend Other None Delivery attendant Figure 6: Delivery attendant for Sierra Leonean women, 2009-2013 (N=8446) 49 Percentage Percentage University of Ghana http://ugspace.ug.edu.gh 4.4 Determinants of utilization of Antenatal care 4.4.1 Bivariate association for place of antenatal care Table 5: Socio-demographic Characteristics of respondents from the 2013 Sierra Leone Demographic and health survey and association with type of place of antenatal care (N=8,272) Fisher exact Socio-demographic Type of place of ANC p- X2 P- Characteristics Non-health facility Health facility *X2 value value Total (%) (%) (%) Wealth Index Poorest 1,681 (20.3) 31 (29.0) 1,650 (20.2) Poorer 1,576 (19.1) 19 (17.8) 1,557 (19.2) Middle 1,630 (19.7) 18 (16.8) 1,612 (19.7) 5.80 0.22 Richer 1,930 (23.3) 25 (23.4) 1,905 (23.3) Richest 1,455 (17.6) 14 (13.0) 1,441 (17.6) Religion No religion 29 (0.4) 0 (0.00) 29 (0.4) Christianity 1,648 (19.9) 19 (17.8) 1,629 (19.9) 0.81 Islam 6,572 (79.4) 88 (82.2) 6,484 (79.4) Traditional/others 23 (0.3) 0 (0.00) 23 (0.3 ) Region Western 905(11.0) 13 (12.2) 896 (11.0) Northern 3,366 (40.7) 53 (49.5) 3,313 (40.6) 4.68 0.20 Eastern 1,623 (19.6) 15 (14.0) 1,608 (19.7) Southern 2,374 (28.7) 26 (24.3) 2,348 (28.7) Marital Status Never married 845 (10.2) 8 (7.5) 837 (10.3) Married 6,521 (78.8) 86 (8.4) 6,435 (78.8) Cohabiting 269 (3.3) 4 (3.7) 265 (3.2) 0.78 Separated/Divorced/ 637 (7.7) 9 (8.4) 628 (7.7) widowed Education No education 5,590 (67.6) 76 (71.0) 5,514 (67.5) Primary 1,045 (12.6) 18 (16.8) 1,027 (12.6) 0.07 Secondary 1,451 (17.5) 10 (9.4) 1,441 (17.6) Higher 186 (2.3) 3 (2.8) 186 (2.3) Place of residence Urban 2,824 (34.1) 27 (25.2) 2,797 (34.3) 3.82 **0.04 Rural 5,448 (65.9) 80 (74.8) 5,368 (65.7) Age 15-19 619 (7.5) 5 (4.7) 614 (7.5) 2.51 0.87 50 University of Ghana http://ugspace.ug.edu.gh 20-24 1,299 (15.7) 15 (14.0) 1,284 (15.7) 25-29 1,658 (20.0) 26 (24.3) 1,632 (20.0) 30-34 1,488 (18.0) 20 (24.3) 1,468 (18.0) 35-39 1,454 (17.6) 18 (16.8) 1,436 (17.6) 40-44 853 (10.3) 12 (11.2) 841 (10.3) 45-49 901 (10.9) 11 (10.3) 890 (10.9) Parity 1 1,658 (20.0) 22 (20.6) 1,636 (20.0) 2-4 3,709 (44.8) 49 (45.8) 3,660 (44.8) 0.10 0.95 5+ 2,905 (35.1) 36 (33.6) 2,869 (35.1) Total 8,272(100) 107(100) 8,165(100) Source *chi square **p<0.05. Analysis of the data for type of place of ANC for the 8,272 (67.0 %) respondents in table 5 above shows that the type of place of antenatal care for women was significantly associated with place residence (p<0.05). Women who were residing in urban areas were more likely to receive ANC at a health facility (p=0.04) than those in the rural areas. 4.4.2 Multivariate logistic regression analysis for place of antenatal care Table 5 below shows the multivariate logistic regression result for the association between place of ANC and the independent variables. The result showed that women between the age 25-29 years had 74% reduction in the odds of receiving ANC from the health facility (OR 0.26; 95% CI 0.08-0.88) compared to those aged between 15- 19 while controlling for all other variables in the model. Also, women who were living in rural areas had 35% reduction in the odds of receiving antenatal care from a health facility (OR=0.65 95% CI 0.37-1.10) as compared to women living in urban areas. But after Adjusting for all the other variables in the model the effect place of residence was found not significant. 51 University of Ghana http://ugspace.ug.edu.gh Table 6: Crude and Adjusted odds ratios showing association between type of place of antenatal care from the 2013 SLDHS and selected socio-demographic characteristics Socio-demographic Crude odds ratio P-value Adjusted odds ratio P-value characteristics (95% CI) (95% CI) age 15-19 (Ref) 1 1 20-24 0.49 (0.15 – 1.61) 0.24 0.41 (0.12 – 1.35) 0.14 25-29 0.36 (0.12 – 1.13) 0.08 0.26 (0.08 – 0.88) **0.03 30-34 0.51 (0.15 – 1.67) 0.26 0.34 (0.10 – 1.18) 0.09 35-39 0.57 (0.18 – 1.85) 0.35 0.35 (0.10 – 1.23) 0.10 40-44 0.51 (0.16 – 1.56) 0.23 0.30 (0.09 – 1.06) 0.06 45-49 0.68 (0.20 – 2.30) 0.54 0.41 (0.10 – 1.70) 0.22 Place of residence Urban (Ref) 1 1 Rural 0.65 (0.37 – 1.10) **0.04 0.64 (0.26 – 1.56) 0.32 Education No education (Ref) 1 1 Primary 0.65 (0.36 – 1.16) 0.14 0.64 (0.36 – 1.15) 0.14 Secondary and Higher 1.97 (0.94 – 4.12) 0.07 2.00 (0.95 – 4.23) 0.07 Region Western (Ref) 1 1 Northern 0.75 (0.37 – 1.49) 0.41 1.04 (0.50 – 2.19) 0.90 Eastern 1.26 (0.43 – 3.67) 0.67 1.64 (0.55 – 4.84) 0.37 Southern 1.26 (0.56 – 2.79) 0.59 1.70 (0.73 – 3.99) 0.22 Wealth Index Poorest (Ref) 1 1 Poorer 1.07 (0.56 – 2.04) 0.83 1.14 (0.60 – 2.17) 0.69 Middle 1.01 (0.51 – 2.03) 0.97 1.08 (0.53 – 2.17) 0.84 Richer 0.91 (0.44 – 1.95) 0.79 0.77 (0.33 – 1.84) 0.56 Richest 1.43 (0.69 – 2.95) 0.34 0.97 (0.35 – 2.72) 0.96 Parity 1 (Ref) 1 1 2-4 1.04 (0.62 – 1.77) 0.88 1.65 (0.93 – 2.91) 0.09 5+ 1.30 (0.73 – 2.33) 0.37 2.01 (0.96 – 4.40) 0.06 Source **p<0.05. (Ref)-reference category 52 University of Ghana http://ugspace.ug.edu.gh 4.4.3 Bivariate association for provider of antenatal care Although majority of the respondents received antenatal care from skilled providers (nurse or midwife, MCH Aide and doctors) during the five (5) years period, table 6 below shows that the difference was not statistically significant for most of the variables. However, women who were living in the urban area had a significant greater chance of being seen by a skilled provider compare to those living in the rural area (P=0.04). Table 7: Association between the type of provider of antenatal care from then 2013 SLDHS and socio-demographic characteristics Socio-demographic Type of provider of ANC X2 Fisher X2 P- characteristic Unskilled provider Skilled provider exact value (%) (%) p- Total (%) value Wealth Index Poorest 1,716 (20.3) 101 (18.6) 1,615 (20.5) Poorer 1,599 (19.) 99 (18.3) 1,500 (19.0) Middle 1,651 (19.6) 102 (18.8) 1,549 (19.6) 2.70 0.608 Richer 1,965 (23.3) 134 (24.7) 1,831 (23.2) Richest 1,498 (17.8) 106 (19.6) 1,392 (17.7) Religion No religion 29 (0.3) 1 (0.2) 28 (0.3) Christianity 1,714 (20.3) 116 (21.4) 1,598 (20.3) 0.91 Islam 666 (79.1) 424 (72.2) 6,239 (79.1) Traditional/others 23 (0.3) 1 (0.2) 22 (0.3) Region Western 909 (10.8) 69 (12.7) 840 (10.6) Northern 3,366 (39.9) 226 (41.7) 3,140 (39.8) 5.84 0.12 Eastern 1,711 (20.3) 112 (20.7) 1,599 (20.3) Southern 2,443 (29.0) 135 (24.9) 2,308 (29.3) Marital Status Never married 865 (10.3) 56 (10.3) 809 (10.3) Married 6,651(78.9) 434 (85.1) 6,217 (78.8) Cohabiting 273 (3.2) 21 (3.9) 252 (3.2) 3.50 0.32 Separated/Divorced/ 640 (7.6) 31 (5.7) 609 (7.7) widowed Education No education 5,692 (67.5) 372 (68.6) 5,320 (67.5) Primary 1,063 (12.6) 61 (11.3) 1,002 (12.7) 1.65 0.648 Secondary 1,484 (17.6) 94 (17.3) 1,390 (17.6) Higher 190 (2.3) 15 (2.8) 175 (2.2) Place of residence 4.17 **0.04 53 University of Ghana http://ugspace.ug.edu.gh Urban 2,895 (34.3) 208 (58.4) 2,687 (34.1) Rural 5,534 (65.7) 334 (61.6) 5,200 (65.9) Age 15-19 262 (7.4) 42 (7.7) 584 (7.4) 20-24 1,326 (15.7) 80 (14.8) 1,246 (15.8) 25-29 1,694 (20.1) 102 (18.8) 1,592 (20.2) 30-34 1,510 (17.9) 110 (20.3) 1,400 (17.7) 7.04 0.32 35-39 1,484 (17.6) 105 (19.4) 1,397 (17.5) 40-44 872 (10.4) 43 (7.9) 829 (10.5) 45-49 917 (10.9) 60 (11.1) 857 (10.9) Parity 1 1,693 (20.1) 100 (18.4) 1,593 (20.2) 1.32 0.57 2-4 3,780 (44.8) 254 (46.9) 3,526 (44.7) 5+ 2,956 (35.1) 188 (34.7) 2,768 (35.1) Total 8,429(100) 542(100) 7,887(100) Source: **p<0.05. (Ref)-reference category, x2: chi square 4.4.4 Multivariate logistic regression analysis for provider of antenatal care The multivariate logistic regression analysis for the association between type of ANC provider and the independent variables from table 7 below shows that the odds of utilizing skilled ANC provider is 83% less (OR 0.17; 95% CI: 0.04-0.81) for women who were Christians, and 80% less (OR 0.20; 95% CI: 0.04-0.92) for Muslims compared to those who have no religion or belong to other religion, while controlling for other variables in the model. 54 University of Ghana http://ugspace.ug.edu.gh Table 8: Crude and adjusted odd ratios showing association between ANC provider and socio-demographic characteristics Socio-demographic characteristics Crude Odd ratio P-value Adjusted Odd P-value Ratio Marital Status Never married(Ref) 1 1 Married/Cohabiting 0.98(0.70-1.38) 0.92 0.88(0.60-1.30) 0.53 Separated/Divorced/widowed 1.39(0.85-2.27) 0.19 1.28(0.75-2.18) 0.37 Religion No religion/Others(Ref) 1 1 Christianity 0.17(0.04-0.79) 0.02 0.17(0.04-0.81) **0.03 Islam 0.19(0.04-0.87) 0.03 0.20(0.04-0.92) **0.04 Parity 1(Ref) 1 1 2-4 0.99(0.77-1.28) 0.94 0.97(0.73-1.29) 0.85 5+ 1.08(0.79-1.47) 0.64 1.03(0.69-1.56) 0.87 Region Western(Ref) 1 1 Northern 1.18(0.68-2.05) 0.55 1.02(0.56-1.84) 0.96 Eastern 1.15(0.63-2.10) 0.64 1.05(0.56-1.97) 0.88 Southern 1.29(0.69-2.43) 0.43 1.15(0.57-2.32) 0.69 Wealth index Poorest(Ref) 1 1 Poorer 1.10(0.78-1.54) 0.59 1.11(0.79-1.56) 0.55 Middle 0.96(0.68-1.35) 0.82 0.98(0.70-1.39) 0.92 Richer 0.84(0.59-1.21) 0.35 0.95(0.65-1.38) 0.77 Richest 0.78(0.50-1.23) 0.28 0.98(0.61-1.59) 0.94 Place of residence Urban(Ref) 1 1 Rural 1.35(0.94-1.94) 0.10 1.33(0.88-2.01) 0.17 Education No education(Ref) 1 1 Primary 1.18(0.86-1.63) 0.31 1.25(0.88-1.77) 0.20 Secondary and Higher 0.95(0.72-1.24) 0.68 1.11(0.81-1.52) 0.51 Age 15-19(Ref) 1 1 20-24 1.01(0.64-1.59) 0.97 1.06(0.66-1.70) 0.80 25-29 1.09(0.72-1.65) 0.68 1.18(0.76-1.85) 0.46 30-34 0.87(0.58-1.32) 0.52 0.93(0.58-1.51) 0.78 55 University of Ghana http://ugspace.ug.edu.gh 35-39 0.94(0.61-1.45) 0.79 1.00(0.60-2.66) 1.00 40-44 1.40(0.96-2.20) 0.14 1.49(0.83-2.66) 0.18 45-49 1.07(0.68-1.69) 0.77 1.10(0.63-1.92) 0.74 Source: **p<0.05. (Ref)-reference category 4.4.5 Bivariate association and Multivariate logistic regression analysis number of antenatal care visits The association between the socio-demographic characteristic of the respondents and the number of antenatal visits made during the five (5) years period were found to be statistically not significant by both bivariate and multivariate analysis. Tables 7 & 8 show the results for the analysis. 56 University of Ghana http://ugspace.ug.edu.gh Table 9: Association between the independent variables and the number of antenatal visits 2009-2013 (N=8,478) Socio-demographic Number of ANC visits X2 P value characteristic Total (%) 0-3 (%) 4+ (%) Wealth Index Poorest 1,734 (20.4) 182 (19.5) 1,552 (20.6) Poorer 1,600 (18.9) 183 (19.6) 1,417 (18.8) Middle 1,660 (19.6) 174 (18.6) 1,486 (19.7) 2.16 0.71 Richer 1,977 (23.3) 231 (24.7) 1,746 (23.1) Richest 1,507 (17.8) 165 (17.6) 1,342 (17.8) Religion No religion/Others 53 (0.6) 8 (0.9) 45 (0.6) Christianity 1,722 (20.3) 177 (18.9) 1,545 (20.5) 2.06 0.36 Islam 6,703 (79.1) 750 (80.2) 5,953 (78.9) Region Western 909 (10.7) 94 (10.1) 815 (10.8) Northern 3,366 (39.7) 367 (39.2) 2,999 (39.8) 0.96 0.81 Eastern 1,760 (20.8) 203 (21.7) 1,557 (20.6) Southern 2,443 (28.8) 271 (29.0) 2,172 (28.8) Marital Status Never married 870 (10.3) 92 (9.8) 778 (10.3) Married/Cohabiting 6,963 (82.1) 765 (81.8) 6,198 (82.2) 0.94 0.63 Separated/Divorced/ 645 (7.6) 78 (8.3) 567 (7.5) widowed Education No education 5,727 (67.5) 627 (67.1) 5,100 (67.6) Primary 1,067 (12.6) 116 (12.4) 951 (12.6) 0.30 0.86 Secondary and Higher 1,684 (19.9) 1192 (20.5) 1,492 (19.8) Place of residence Urban 2,919 (34.4) 325 (34.8) 2,594 (34.4) 0.05 0.82 Rural 5,559 (65.6) 610 (65.2) 4,949 (65.6) Age 15-19 631 (7.4) 71 (7.6) 560 (7.4) 20-24 1,331 (15.7) 146 (15.6) 1,185 (15.7) 25-29 1,702 (20.1) 197 (21.1) 1,505 (19.9) 30-34 1,519 (17.9) 163 (17.4) 1,356 (18.0) 1.68 0.95 35-39 1,493 (17.6) 162 (17.3) 1,331 (17.6) 40-44 876 (10.3) 89 (9.5) 787 (10.4) 45-49 926 (10.9) 107 (11.4) 819 (10.9) Parity 1-2 1,700 (20.0) 190 (20.3) 1,510 (20.0) 3-4 3,803 (44.9) 407 (43.5) 3,396 (45.0) 0.79 0.68 5+ 2,975 (35.1) 338 (36.2) 2,637 (35.0) Total 8,478(100) 935(100) 7,543(100) 57 University of Ghana http://ugspace.ug.edu.gh Table 10: Crude and Adjusted Odds Ratio showing association between the socio- demographic characteristics and number of ANC visits from the 2013 Sierra Leone Demographic and health survey Background Crude odds ratio P-Value Adjusted odds ratio P-value characteristics (95% CI) (95% CI) age 15-19 (Ref) 20-24 0.97 (0.69 – 1.35) 0.84 0.95 (0.67 – 1.33) 0.75 25-29 0.95 (0.70 – 1.30) 0.74 0.92 (0.65 – 1.29) 0.63 30-34 1.09 (0.79 – 1.52) 0.60 1.09 (0.73 – 1.61) 0.68 35-39 1.00 (0.73 – 1.40) 0.96 1.02 (0.69 – 1.52) 0.90 40-44 1.24 (0.85 – 1.80) 0.26 1.29 (0.85 – 1.09) 0.24 45-49 1.03 (0.70 – 1.53) 0.88 1.10 (0.71 – 1.73) 0.66 Place of residence Urban (Ref) Rural 1.04 (0.80 – 1.36) 0.75 1.09 (0.78 – 1.53) 0.60 Education No education (Ref) Primary 1.09 (0.86 – 1.39) 0.45 1.11 (0.87 – 1.42) 0.40 Secondary and Higher 0.91 (0.73 – 1.13) 0.39 0.91 (0.73 – 1.13) 0.38 Region Western (Ref) Northern 0.91 (0.63 – 1.29) 0.59 0.90 (0.59 – 1.38) 0.62 Eastern 0.97 (0.64 – 1.47) 0.89 0.97 (0.60 – 1.56) 0.90 Southern 0.83 (0.56 – 1.24) 0.36 0.82 (0.51 – 1.31) 0.40 Wealth Index Poorest (Ref) Poorer 0.84 (0.65 – 1.07) 0.16 0.82 (0.64 – 1.6) 0.13 Middle 1.00 (0.76 – 1.30) 0.99 0.99 (0.76 – 1.30) 0.95 Richer 0.91 (0.69 – 1.19) 0.48 0.94 (0.71 – 1.27) 0.73 Richest 0.97 (0.68 – 1.39) 0.86 1.03 (0.65 – 1.61) 0.91 Parity 1-2 (Ref) 3-4 1.10 (0.89 – 1.35) 0.38 1.05 (0.83 – 1.32) 0.69 5+ 1.07 (0.86 – 1.32) 0.55 0.94 (0.70 – 1.27) 0.69 Marital Status Never married (Ref) Married/Cohabiting 1.06 (0.82 – 1.38) 0.64 0.98 (0.73 – 1.30) 0.86 Separated/Divorced/ 0.89 (0.63 – 1.26) 0.50 0.79 (0.56 – 1.18) 0.18 widowed 58 University of Ghana http://ugspace.ug.edu.gh Religion No religion/Other (Ref) 1 1 Christianity 1.46 (0.63 – 3.38) 0.38 1.40 (0.61 – 3.23) 0.43 Islam 1.46 (0.63 – 3.37) 0.37 1.38 (0.60 – 3.16) 0.45 4.5 Determinants of utilization of Delivery care 4.5.1 Bivariate association for place of delivery Result from the bivariate analysis on table 9 below shows a significant strong association between place of delivery and the following independent variables: wealth index, religion, region and marital status (p<0.05). There was no association between place of delivery and the variables age, parity, place of residence and education (p>0.05). Table 11: Socio-demographic Characteristics of delivery care users from the 2013 Sierra Leone Demographic and health survey and association with place of delivery (N=8,446) Socio-demographic characteristic Place of Delivery X2 P value Health Non health Total (%) facility (%) facility (%) Wealth Index Poorest 1,729 (20.5) 1,072 (21.6) 657(18.8) Poorer 1,600 (18.9) 955 (19.3) 645 (18.5) ** Middle 1,653 (19.6) 949 (19.2) 704 (20.2) 13.39 0.01 Richer 1,966 (23.3) 1,126 (22.7) 840 (24.0) Richest 1,498 (17.7) 851 (17.2) 647 (18.5) Religion No religion 29 (0.3) 14 (0.3) 15 (0.4) Christianity 1,716 (20.3) 1,004 (20.3) 712 (20.4) 11.45 **0.01 Islam 6,678 (79.1) 3,929 (79.3) 2,749 (78.7) Traditional/others 23 (0.3) 6 (0.1) 17 (0.5) Region Western 909 (10.8) 510 (10.3) 399 (11.4) Northern 3,366 (39.8) 1,931 (39.0) 1,435 (41.1) 9.59 **0.02 Eastern 1,728 (20.5) 1,053 (21.3) 675 (19.3) Southern 2,443 (28.9) 1,459 (29.4) 984 (28.2) Marital Status 8.42 **0.04 59 University of Ghana http://ugspace.ug.edu.gh Never married 865 (10.2) 472 (9.5) 393 (11.3) Married 6,668 (79.0) 3,924 (79.2) 2,744 (78.6) Cohabiting 273 (3.2) 163 (3.3) 110 (3.1) Separated/Divorced/widowed 640 (7.6) 394 (8.0) 246 (7.0) Education No education 5,704 (67.5) 3,364 (67.9) 2,340 (67.0) Primary 1,065 (12.6) 642 (13.0) 423 (12.1) 4.71 0.10 Secondary and Higher 1,677 (19.9) 947 (19.1) 730 (20.9) Place of residence Urban 2,895 (34.3) 1,666 (33.6) 1,229 (35.2) 2.18 0.14 Rural 5,551 (65.7) 3,287 (66.4) 2,264 (64.8) Age 15-19 628 (7.4) 366 (7.4) 262 (7.5) 20-24 1,330 (15.8) 791 (16.0) 539 (15.4) 25-29 1,697 (20.1) 958 (19.3) 739 (21.2) 30-34 1,511 (17.9) 902 (18.2) 609 (17.4) 6.93 0.33 35-39 1,487 (17.6) 891 (18.0) 596 (17.1) 40-44 872 (10.3) 496 (10.0) 376 (10.8) 45-49 921 (10.9) 549 (11.1) 372 (10.6) Parity 1 1,695 (20.1) 975 (19.7) 720 (20.6) 2-4 3,787 (44.8) 2,214 (44.7) 1,573 (45.0) 1.86 0.40 5+ 2,964 (35.1) 1,764 (35.61) 1,200 (34.4) Total 8,446(100) 4,953(100) 3,493(100) Source: **p<0.05. 4.5.2 Multivariate logistic regression analysis for place of delivery The result of multivariate analysis of place of delivery and it association with socio-demographic characteristics is shown in table 10. Women who marital status were categorized as separated/divorced/widowed used had 38% higher odds of delivery in a health facility (OR 1.38; 95% CI 1.04-1.82) as compared to those who were categorized as never married while controlling for other variables. Religion was also related with use of health facility for delivery. The result is statistically significant for women who practice traditional/other religion. They have 25% less odds of delivery in a health facility (OR 0.25; 95% CI 0.07- 0.92) compared to those with no religion while controlling for other variables. 60 University of Ghana http://ugspace.ug.edu.gh The result for parity for those having five (5) or more children was found significant when unadjusted, but after controlling for other variables it was found statistically not significant. Similarly, the result was not statistically significant for the remaining other socio-demographic characteristics. Table 12: Crude and Adjusted Odds Ratio showing association between place of delivery from the 2013 Sierra Leone Demographic and health survey and background characteristics Socio-demographic Crude odds ratio P-Value Adjusted odds ratio P-value characteristics (95% CI) (95% CI) age 15-19 (Ref) 1 1 20-24 1.07 (0.86 – 1.32) 0.54 1.01 (0.81 – 1.27) 0.91 25-29 0.91 (0.72 – 1.14) 0.40 0.80 (0.62 – 1.03) 0.09 30-34 1.06 (0.85 – 1.33) 0.62 0.88 (0.68 – 1.15) 0.36 35-39 1.10 (0.89 – 1.37) 0.37 0.89 (0.67 – 1.17) 0.40 40-44 1.02 (0.80 – 1.29) 0.90 0.80 (0.59 – 1.09) 0.15 45-49 1.08 (0.85 – 1.38) 0.52 0.84 (0.61 – 1.14) 0.26 Place of residence Urban (Ref) 1 1 Rural 1.01 (0.79 – 1.30) 0.94 0.98 (0.75 – 1.28) 0.87 Education No education (Ref) 1 1 1 Primary 1.09 (0.91 – 1.29) 0.38 1.08 (0.91 – 1.30) 0.38 Secondary and Higher 0.91 (0.75 – 1.10) 0.31 0.94 (0.78 – 1.13) 0.51 Region Western (Ref) 1 1 Northern 0.99 (0.64 – 1.52) 0.96 0.94 (0.60 – 1.50) 0.80 Eastern 1.03 (0.66 – 1.60) 0.89 0.98 (0.62 – 1.55) 0.93 Southern 1.01 (0.66 – 1.55) 0.97 0.97 (0.61 – 1.52) 0.88 Parity 1-2 (Ref) 1 1 3-4 1.05 (0.91 – 1.22) 0.51 1.10 (0.89 – 1.27) 0.53 5+ 1.18 (1.02 – 1.38) **0.03 1.21 (0.96 – 1.52) 0.10 61 University of Ghana http://ugspace.ug.edu.gh Marital Status Never married (Ref) 1 1 Married 1.20 (0.98 – 1.47) 0.08 1.19 (0.96 – 1.48) 0.12 Cohabiting 1.05 (0.75 – 1.48) 0.77 1.04 (0.74 – 1.47) 0.81 Separated/Divorced/ 1.38 (1.06 – 1.79) **0.02 1.38 (1.04 – 1.82) **0.02 widowed Religion No religion (Ref) 1 1 Christianity 0.97 (0.42 – 2.25) 0.95 1.03 (0.45 – 2.36) 0.95 Islam 0.95 (0.41 – 2.22) 0.91 0.97 (0.43 – 2.23) 0.95 Traditional/others 0.24 (0.06 – 0.88) **0.03 0.25 (0.07 – 0.92) **0.04 Source: **p<0.05. (Ref)-reference category 4.5.3 Bivariate association for delivery attendant In analysis of the determinants of “utilization of attendant” during delivery, an additional variable called “use of antenatal care” was included. This is because this variable can serve as a strong positive predictor for use of assistance during delivery. Results from the bivariate analysis are shown on table 11 below. Women who utilized skilled attendant at delivery were different statistically from those who utilized unskilled attendant by wealth index, religion, use of antenatal care and region (p<0.05). No significant differences were observed by marital status, education, place of residence, age and parity (p>0.05). 62 University of Ghana http://ugspace.ug.edu.gh Table 13: Socio-demographic Characteristics of delivery care users from the 2013 Sierra Leone Demographic and health survey and association with category of delivery attendant (N=8,446) Socio-demographic characteristic Category of delivery Chi P value attendant square Total (%) *SBA(%) *UBA(%) Wealth Index Poorest 1,729 (20.5) 1,168 (21.5) 561 (18.6) Poorer 1,600 (18.9) 1,052 (19.4) 548 (18.2) ** Middle 1,653 (19.6) 1,040 (19.1) 613 (20.4) 14.220 0.01 Richer 1,966 (23.3) 1,229 (22.6) 737 (24.5) Richest 1,498 (17.7) 948 (17.4) 550 (18.3) Religion No religion 29 (0.3) 16 (0.3) 13 (0.4) Christianity 1,716 (20.3) 1,112 (20.5) 604 (20.1) 9.992 **0.02 Islam 6,678 (79.1) 4,301 (79.1) 2,377 (79.0) Traditional/others 23 (0.3) 8 (0.1) 15 (0.5) Antenatal care No 168(2.0) 88(1.6) 809(26.9) 10.75 **<0.01 Yes 8,278(98.0) 5,437(98.4) 2,929(73.1) Region Western 909 (10.8) 5,571 (10.5) 338 (11.2) Northern 3,366 (39.8) 2,113 (38.9) 1,435 (41.6) 12.337 **0.01 Eastern 1,728 (20.5) 1,166 (21.4) 562 (18.7) Southern 2,443 (28.9) 1,587 (29.2) 856 (28.5) Marital Status Never married 865 (10.2) 534 (9.8) 331 (11.0) Married 6,668 (79.0) 4,293 (79.0) 2,375 (78.9) 5.05 0.17 Cohabiting 273 (3.2) 184 (3.4) 89 (3.0) Separated/Divorced/widowed 640 (7.6) 426 (7.8) 214 (7.1) Education No education 5,704 (67.5) 3,691 (67.9) 2,013 (66.9) Primary 1,065 (12.6) 696 (12.8) 369 (12.3) 2.99 0.22 Secondary and Higher 1,677 (19.9) 1,050 (19.3) 627 (20.8) Place of residence Urban 2,895 (34.3) 1,830 (33.7) 1,065 (35.4) 2.59 0.11 Rural 5,551 (65.7) 3,607 (66.3) 2,264 (64.6) Age 15-19 628 (7.4) 408 (7.5) 220 (7.3) 20-24 1,330 (15.8) 869 (16.0) 461 (15.3) 25-29 1,697 (20.1) 1,073 (19.7) 624 (20.7) 5.64 0.47 30-34 1,511 (17.9) 993 (18.3) 518 (17.2) 35-39 1,487 (17.6) 968 (17.8) 519 (17.2) 40-44 872 (10.3) 540 (9.9) 332 (11.0) 63 University of Ghana http://ugspace.ug.edu.gh 45-49 921 (10.9) 586 (10.8) 335 (11.1) Parity 1 1,695 (20.1) 1,084 (19.9) 611 (20.3) 2-4 3,787 (44.8) 2,427 (44.6) 1,360 (45.2) 0.74 0.69 5+ 2,964 (35.1) 1,926 (35.4) 1,038 (34.5) Total 8,446(100) 5,437(100) 3,009(100) Source: **p<0.05. (Ref)-reference category *SBA: Skilled Birth Attendant (Doctors, Nurse or midwife and MCH Aide) *UBA: Unskilled Birth Attendant (TBA, Relative/Friends, CHO) 4.5.4 Multivariate logistic regression analysis for delivery attendant The result of multivariate analysis in table 12 below shows that women who used antenatal care service had a 72% higher odds of utilizing a skilled attendant during delivery (OR 1.72; 95% CI 1.17-2.51) as compared to those who did not use antenatal care services while controlling for other variables. Household wealth was also related with used of skilled attendant during delivery. The result is statistically significance for women in the middle wealth group, having 29% less odds of utilizing a skilled attendant during delivery (OR 0.71; 95% CI 0.56- 0.90). The result was not statistically significant for the other socio-demographic characteristics. Table 14: Crude and Adjusted Odds Ratio showing association between category of delivery attendant from the 2013 Sierra Leone Demographic and health survey and background characteristics Background Crude odds ratio P-Value Adjusted odds ratio P-value characteristics (95% CI) (95% CI) age 15-19 (Ref) 1 1 20-24 0.98 (0.78 – 1.23) 0.84 0.95 (0.74 – 1.21) 0.67 25-29 0.88 (0.70 – 1.13) 0.34 0.81 (0.61 – 1.07) 0.13 30-34 0.96 (0.76 – 1.22) 0.74 0.84 (0.62 – 1.10) 0.19 35-39 0.98 (0.78 – 1.24) 0.90 0.83 (0.61 – 1.11) 0.21 40-44 0.88 (0.68 – 1.14) 0.34 0.73 (0.53 – 1.01) 0.06 45-49 0.93 (0.71 – 1.21) 0.58 0.76 (0.54 – 1.05) 0.10 Place of residence 64 University of Ghana http://ugspace.ug.edu.gh Urban (Ref) 1 1 Rural 1.04 (0.80 – 1.35) 0.77 1.04 (0.76 – 1.43) 0.78 Education No education (Ref) 1 1 1 1 Primary 1.10 (0.92 – 1.31) 0.29 1.10 (0.92 – 1.31) 0.30 Secondary and Higher 0.97 (0.79 – 1.18) 0.76 1.01 (0.84 – 1.22) 0.93 Region Western (Ref) 1 1 Northern 0.91 (0.58 – 1.42) 0.68 0.88 (0.55 – 1.43) 0.61 Eastern 1.07 (0.67 – 1.73) 0.77 1.02 (0.62 – 1.67) 0.95 Southern 0.95 (0.60 – 1.51) 0.34 0.89 (0.54 – 1.45) 0.64 Wealth Index Poorest (Ref) 1 1 Poorer 0.81 (0.64 – 1.04) 0.10 0.81 (0.64 – 1.03) 0.08 Middle 0.70 (0.56 – 0.89) <0.01 0.71 (0.56 – 0.90) **0.01 Richer 0.81 (0.62 – 1.06) 0.13 0.83 (0.63 – 1.11) 0.22 Richest 0.81 (0.60 – 1.10) 0.18 0.84 (0.60 – 1.21) 0.36 Antenatal care No(Ref) 1 1 Yes 1.76(1.20-2.60) **<0.01 1.72(1.17-2.51) **0.01 Parity 1 (Ref) 1 1 2-4 1.00 (0.87 – 1.16) 0.95 1.04 (0.88 – 1.26) 0.59 5+ 1.10 (0.93 – 1.29) 0.26 1.21 (0.96 – 1.55) 0.11 Marital Status Never married (Ref) 1 1 Married 1.11 (0.89 – 1.37) 0.36 1.14 (0.90 – 1.44) 0.26 Cohabiting 1.08 (0.74 – 1.56) 0.70 1.08 (0.74 – 1.58) 0.68 Separated/Divorced/ 1.25 (0.94 – 1.65) 0.12 1.32 (0.98 – 1.79) 0.06 widowed Religion No religion (Ref) 1 1 Christianity 1.17 (0.50 – 2.74) 0.73 1.14 (0.48 – 2.76) 0.77 Islam 1.12 (0.48 – 2.64) 0.86 1.10 (0.47 – 2.58) 0.82 Traditional/others 0.30 (0.08 – 1.06) 0.06 0.31 (0.09 – 1.13) 0.08 Source: **p<0.05. (Ref)-reference category 65 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION 5.1 Introduction This chapter focus on the discussion of the findings of this study with respect to the determinants of utilization antenatal and delivery care services. This study has identified a number of factors that had significant influence on utilization of maternal health care services in Sierra Leone during the five year period before the 2013 SLDHS. 5.2 Determinants of utilization of ANC services Findings from this study show that Sierra Leonean women utilize ANC services far more than delivery care services. It was found out that a greater proportion of the women made use of the ANC services during pregnancy. Seen from the results of number of ANC visits during pregnancy, about 98.0 % of the women made at least one ANC visit. Almost 89 % of those that used ANC services completed the WHO recommended four or more ANC visits that were in use at that time. Comparing this finding to a recent study conducted in Ethiopian which also analyzed data from the 2014 Ethiopian Mini Demographic and Health Survey, only 33.0 % of women completed the four or more ANC visits. The finding of the Ethiopian study also shows that variables such as age, education, region, residence (urban or rural), and household wealth index were significant predictors for completing four or more ANC. However, in this study, these socio-demographic variables were not significant determinants of the four or more ANC visits (Muchie Kindie Fentahun, 2017). 66 University of Ghana http://ugspace.ug.edu.gh The use of ANC in Sierra Leone during the five year period before the survey was also much higher compare to the 42.9 % use of ANC services for at least one visit in Ethiopian(Shegaw M. Tarekegn, Lieberman, & Giedraitis, 2014), and 60.3 % in Nigeria(Babalola & Fatusi, 2009). In this study, it was found out that the government health facilities were the most common place were women went for ANC. This a case for almost 98% of the women who had at least one ANC visits. The reason for this can be attributed to the availability and accessibility of the government health facilities for minimal costs or for free of charge following implementation of the free maternal and under five children health care in 2010. This study also reveals that about 94 % of the ANC services were provided by skilled providers (Nurse or midwife, MCH Aide and Doctors). The proportion of the pregnant women that were seen by these skilled providers includes: doctors 2%, Nurse or midwife 58% and MCH Aid 34%. This finding is comparable to the finding from a similar study done in Ghana which also reveals that majority of the pregnant women are seen by nurse or midwife (doctors provided 17.8%, Nurse or Midwife 83% and Auxiliary Midwife 2.2%). The proportion of women who received antenatal care from unskilled providers was 6% in this study, whereas the proportion in the Ghana study was 1.2% (Adanu, 2017). The significant determinants of utilization of ANC identified in this study are place of residence, age and religion. More women in the urban areas had ANC in health facilities compared to those in the rural area. However, the use of skilled ANC provider was more common among those in the rural areas (65%) than those in urban area (35%). This finding is contrary to the findings of the Ethiopian 67 University of Ghana http://ugspace.ug.edu.gh study where 76% and 24 % of the urban and rural women respectively used skilled ANC provider (Shegaw M. Tarekegn et al., 2014). The reason for the higher rural proportion of skilled ANC provider users can be attributed to the greater rural population of Sierra Leone. Nearly 70% of the population of Sierra Leone are found in the rural areas. Christians and Muslims women were found to utilize the non-health facilities for ANC more than the health facilities, compared to those with no religion or other religion. Women between the ages 25-29 years were also found to utilize the non-health facilities for ANC more than the health facilities compared those aged between 15-19 years. Even though there were variations in the proportion of women who utilized ANC services with respect to their socio-demographic characteristics, this study, however, found some these characteristics (wealth index, region, religion, education and parity) not significant in determining the use of ANC services. This finding contradict the findings of a similar study conducted in Ghana which show that the use of ANC improves with wealth index and level of education; and reduce with increase parity of the women (Arthur, 2012). In this study, more than two third of the respondents have no education. About 3 in 5 of the women residing in the rural areas (especially those in the southern, eastern and northern regions of the country) are found in households labelled as poorer and poorest. 68 University of Ghana http://ugspace.ug.edu.gh The Ghana study also shows that women utilize antenatal care more than delivery care. However, in this Ghanaian study, education, region and place of residence were found to be significant determinants of utilization of ANC services (Adanu, 2017). Other findings contradicting the findings of this study were also got from a study conducted in Eritrea. The Eritrea study shows that the use of ANC services were determined by education, age and wealth index (Kibreab Habtom, 2017). Similar contradicting finding was also got from a study done Nigeria. Education was identified a positive predictor for use of ANC services (Umar, 2017). This increase in utilization of antenatal care in Sierra Leone irrespective of the socio- demographic characteristic of the respondents can be attributed to a great increase in antenatal care coverage most probably due to the free maternal health care initiative. Analysis of data on the proportion of women who benefited from the essential components of antenatal care shows the quality of routine ANC coverage in the country during the five years period before the survey. In this study the components were whether a woman’s blood pressure measurement was done, took iron/folic acid supplementation, was told about the signs of pregnancy complications, took drugs to prevent malaria, took tetanus toxoid injection and had urine and blood samples taking for screening tests. Although the proportion of women who benefited from antimalarial prophylaxis (75%) and those told about the signs of pregnancy complications (89%) were low, these proportion of women are higher compared to that reported in the Ghana study were the proportion for antimalarial prophylaxis and told about the signs of pregnancy complications were 55% and 59% respectively (Adanu, 2017). 69 University of Ghana http://ugspace.ug.edu.gh 5.3 Determinant of utilization of delivery care services The utilization of delivery care services was found to be lower despite high use of ANC services. Data analysed for delivery care revealed that only 59 % of the deliveries were institutional deliveries. The remaining 41% were done in the respondent’s home or other homes. This is figure comparable to the 49% home deliveries revealed in the Ghana study (Adanu, 2017). Analysis of data for delivery attendant revealed that only 64 % of the deliveries were done by skilled birth attendants and 37 % by unskilled attendants such TBAs, relatives/friends, community health officers and traditional healers. The determinants of utilization of delivery care identified in this study are household wealth index, religion, region, marital status and use of antenatal care services. Women from households with middle wealth index were found to utilize delivery care services more than those from households with lower wealth index (poorest and poorer). The higher the socio-economic status of the household the higher the utilization of delivery care services. This finding is compatible with the finding of a study done in Rwanda which reported that a higher proportion of health facility deliveries where from among households in the higher and highest wealth classes (Jayaraman, Anuja chandrasekhar, s Gebreselassie, 2008). Another study in Uttarakhand confirms this finding that women from household with higher socio-economic status uses delivery care services more than those from households with lower socio-economic status (Chimankar & Sahoo, 2011). The religious denomination of the women was found to be a significant determinant of utilization of delivery care in this study. Christian and Muslim women were more likely to utilize delivery 70 University of Ghana http://ugspace.ug.edu.gh care services than traditional and other religion. The possible reason for this is that women belonging to the traditional or other religion may not be more modern and they are rooted to traditional beliefs. However, home delivery was found more common among the Muslims. This finding is consistent with findings from the Ethiopia study which revealed that religious denomination of women is an important predictor of Utilization of skilled birth attendant(Shegaw Mulu Tarekegn et al., 2014). Disparity in the use of delivery care services in the four regions of the country was observed in this study. A very significant association was found between region and utilization of delivery care services. Women in the western region made use of delivery care services more than those who were in the other regions. This could be attributed to the differences in the number of maternal health care facilities and skilled providers available in the various regions. Freetown, the capital of Sierra Leone, which is found in the western region have a much higher number of skilled providers than other regions. Similar regional disparity in the use of delivery care services was observed in the Ethiopia study(Shegaw Mulu Tarekegn et al., 2014). The marital status of the women was also a significant determinant of utilization of delivery care services in this study. Separated, divorced or widowed women had institutional delivery more than those categorised as married, cohabiting or never married women. However, the effect of marital status on the utilization of skilled attendant at delivery was found not significant in this study. This finding is consistent with another findings from studies done in Haiti and Kenya (Babalola SO, 2014; Ochako et al., 2011). 71 University of Ghana http://ugspace.ug.edu.gh This study also found out a very significant association between use antenatal care utilization of delivery care services. Women who had ANC visit were found to utilize ANC services more than those with no ANC visit. This confirms the opinion that the use of ANC is important for the use of delivery care as women who had ANC were more likely to have institutional deliveries and use of SBA. This finding is in line with findings of studies done in Kenya, Ethiopia and Haiti (Babalola SO, 2014; Ochako et al., 2011; Shegaw M. Tarekegn et al., 2014). 72 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.1 CONCLUSION AND RECOMMENDATIONS Generally, this study has shown that Sierra Leonean women made used of ANC more than institutional delivery and SBA. More women made the WHO recommended minimum of four ANC visits practice at that time. Although some variations in the utilization of ANC were observed among the women, however, these variations were not significantly associated with the socio-demographic characteristics of the women considered in this study. The health facilities, especially the government health facilities, were more utilized for ANC than the private health facilities. The nurse or midwife and MCH Aide were the main providers of ANC to the women, especially for those in the rural areas. This shows that Sierra Leone has an alarming shortage of obstetrician/gynaecologists or medical doctors that are skilled providers. Also, substantial improvement in the coverage of some essential ANC services was observed, more especially in the aspect early detection of pregnancy induced hypertension and prevention of neonatal tetanus and anaemia in pregnancy. However, much improvement is needed in the aspect of malaria prevention and awareness on danger signs during pregnancy. Provision of quality ANC services is expected to lead to more utilization of delivery care services. This study reveals that, despite the high proportion of ANC users, the utilization of delivery care was generally low during the five year period. The socio-economic status of the women (wealth index), region, religious denomination marital status and use of ANC were identified as the predictors of utilization of delivery care services. 73 University of Ghana http://ugspace.ug.edu.gh It could be concluded that poverty, traditional and religious beliefs, lack of autonomy to use MHC services, region of residence, unavailability, inaccessibility, and inequitable distribution quality MHC services were some of the problems that affected the utilization of MHC services. Based on the findings from this study the following recommendations are therefore made: 1) Multi sectoral approach to be used to tackle this problem. Other ministries, not just the Ministry of Health and sanitation, should be actively involved. Examples of such ministries include: Education, Youth, Gender and Children’s affairs, Agriculture, Transportation, Labour, Information, etc. 2) Religious and traditional leaders should be pro-active in promoting the utilization of MHCS. 3) Improvement of the socio-economic status of the women through improvement on female education in all the four regions and provision of job opportunities. 4) Training of more health care workers especially in the field of maternity care. 5) Expansion and strengthening of MHC programmes in all the regions (especially in the rural areas). Information, education and communication campaign programmes should be provided also. These programmes should be culturally acceptable, need focused and youth friendly. 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Executive Summary, 14. https://doi.org/10 80 University of Ghana http://ugspace.ug.edu.gh APPENDICES 8.1 Appendix A: Sample design for the 2013 sierra Leon demographic and health survey 81 University of Ghana http://ugspace.ug.edu.gh 82 University of Ghana http://ugspace.ug.edu.gh 83 University of Ghana http://ugspace.ug.edu.gh 84 University of Ghana http://ugspace.ug.edu.gh 85 University of Ghana http://ugspace.ug.edu.gh 86 University of Ghana http://ugspace.ug.edu.gh 87 University of Ghana http://ugspace.ug.edu.gh 88 University of Ghana http://ugspace.ug.edu.gh 89 University of Ghana http://ugspace.ug.edu.gh 90 University of Ghana http://ugspace.ug.edu.gh 8.2 Appendix B: 2013 Sierra Leone demographic and health survey woman’s questionnaire 91 University of Ghana http://ugspace.ug.edu.gh 92 University of Ghana http://ugspace.ug.edu.gh 93 University of Ghana http://ugspace.ug.edu.gh 94 University of Ghana http://ugspace.ug.edu.gh 95 University of Ghana http://ugspace.ug.edu.gh 96 University of Ghana http://ugspace.ug.edu.gh 97 University of Ghana http://ugspace.ug.edu.gh 98