文章基本信息

标题：The Role of Health Systems and Policies in Promoting Safe Delivery in Low- and Middle-Income Countries: A Multilevel Analysis
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作者：Margaret E Kruk ; Marta R. Prescott
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2012
卷号：102
期号：4
页码：645-650
DOI：10.2105/AJPH.2011.300462
语种：English
出版社：American Public Health Association
摘要：We aimed to measure the contribution of national factors, particularly health system characteristics, to the individual likelihood of professionally attended delivery (“safe delivery”) for women in low- and middle-income countries. Using Demographic and Health Survey data for 165 774 women in 31 countries, we estimated multilevel logistic regression models to measure the contribution of national economic and health system characteristics to likelihood of attended delivery. More health workers, higher national income, urbanization, and lower income inequality were associated with higher odds of attended delivery. Macrosocial factors increase utilization of attended delivery and may be more efficient in reducing maternal mortality than are interventions aimed at individual women. As of 2010 it appears that Millennium Development Goal (MDG) 5, to reduce by three quarters the maternal mortality ratio between 1990 and 2015, is unlikely to be achieved in many low-income countries. 1,2 Despite the acknowledged importance of professionally attended delivery in reducing maternal mortality, attended delivery rates are low in many parts of the world. 3,4 In the 68 countries that accounted for 97% of child and maternal deaths globally, only half of all deliveries were attended by a health professional, and the rate of increase in professional attendance was among the slowest of all MDG health interventions. 1 Much of the research on low utilization of attended delivery focuses on individual predisposing and enabling factors. However women make delivery decisions within a community and national context, and little is known about the interplay between systemic factors and individuals’ delivery choices. In particular, at a time of rising interest in health system strengthening, to what extent do stronger health systems contribute to greater take-up of this essential service for women with low preexisting likelihood of attended delivery? Multilevel analysis is a method well suited to identifying and quantifying the relative influence of nested determinants on individual outcomes. Only 1 study has used this approach, but that study focused on the effect of maternal age rather than national factors. 5 Building on this work, we aimed to measure the contribution of national factors, particularly health system characteristics, to the individual likelihood of professionally attended delivery (“safe delivery”) for women in low- and middle-income countries. To this end we explored how the national-level determinants mitigate individual-level barriers to professionally attended delivery.