Utilization of full postnatal care services among rural Myanmar women and its determinants: a cross-sectional study

Study participants

The required sample size of 500 participants was estimated based on the multiple logistic regression analysis, as described previously¹⁷. Married women aged 15-49 years who had children aged under 2 years of age and provided informed consent were eligible for this study. Woman who could not communicate properly due to physical or mental ill health were excluded from this study. The eligible samples were obtained by applying multistage cluster sampling method. Firstly, out of 26 townships, 4 were selected by simple random sampling using a lottery. From each township, a random selection of 5 villages (having not less than 18 women who had delivered 2 years prior to the survey) was done. As a result, 500 women fitting the eligibility criteria were recruited in person, with the assistance of local health authorities, from 21 villages by cluster sampling. The 2-year recall period was used to minimize recall bias.

Data collection

Data were collected by face to face interview using semi-structured questionnaires (Supplementary File 1). Reliability of 0.86 was estimated by using Cronbach’s alpha. Validity was arranged by the three experts to obtain the finalized version of questionnaire. Preceding the interview, the researcher trained 10 enumerators for data collection and also explained the objectives and facts to follow while asking the questionnaires. Data were collected after participants had been informed about the purpose of the study, ensuring confidentiality to those taking part in the study.

Assessment of variables

In this study, the outcome variable was utilization of full PNC which was defined as the participants receiving at least four postnatal visits and the first visit within 24 hours of delivery. For analysis, the outcome responses were dichotomized into the women who reported less than four postnatal visits or postnatal care after 24 hours =0 and those who received four or more postnatal visits and the first visit within 24 hours =1. The independent variables measured were as followings: socio-demographic variables such as age of respondents, education level, average monthly per-capita income, male involvement, accessibility to PNC services. Moreover, knowledge of postnatal danger signs and perception on traditional birth attendants (TBAs) were also defined as explanatory variables. Finally, birth order (i.e. the order that the child was born to his/her family), number of AN visits and misconception regarding postnatal practices were considered as important independent variables in this study.

Some independent variables are explained in detail as follows. Male involvement was considered if the woman was provided with transportation assistance for perinatal visits by her husband and the couple had mutual discussion for maternal healthcare usage. Accessibility to maternal care was defined as a combination of the time spent for travelling to the nearest health center and whether the mother could visit there during any season; that is, if the nearest health center was situated within less than 2 hours travelling distance and could be visited during any season, especially rainy season, this was counted as easy accessibility to nearest health center, otherwise, as difficulty in access. Regarding misconceptions, if a woman avoided certain foods, had behavioral restrictions or customs/practices that might threaten the health and survival of mothers and their babies within postnatal period, she belonged to the category of women having misconception on postnatal practices. The outcome variable and most of the independent variables were measured as categorical ones, except age, family income, birth order, numbers of antenatal visits and postnatal visits. However, for more simple analysis and better interpretation purposes, all numerical independent variables were categorized.

Data analysis

The statistical analysis was conducted using the STATA version 13.1. The socio-demographic and background characteristics of respondents were presented as frequencies and percentages for categorical variables and as summary statistics, such as mean ± standard deviation for continuous variables. The full PNC utilization rate with 95% confidence interval (CI) was also described. To explore the determinants on full PNC utilization, odds ratio with 95% CI was estimated using a generalized estimating equation (GEE) under multiple logistic regression framework. To take into account the correlation of an event occurring within the same village (i.e. those in the same village having similar access to a health clinic), for estimation of standard error, the GEE was applied¹⁸. The factors which were significant at p-value less than 0.25 in bivariate analysis were included in the GEE method. All statistical tests were two-sided and p-values less than 0.05 were considered as statistically significant.

Ethical consideration

The Khon Kaen University Ethics Committee for human research with reference number [HE592256] and the Ethical Committee of University of Public Health, Yangon, Myanmar [Ethical (6/2016)] approved this study. Permission to conduct this study was obtained from local responsible persons and health authorities (i.e. village administrative authorities and health authorities from Magway Regional Public Health Department, respectively). Participation in this study was entirely voluntary and informed consent was taken from all participants prior to interview. For participants younger than 18 years, consent was obtained from the individual’s guardian.

Background characteristics of the respondents

Out of 500 respondents, nearly half of them (48.2%) were in the young adult age group of 25 to 35 years. The participants were aged between 17 and 47 years, with a mean age of 29.72±6.6 years (Table 1). Majority of the respondents and their spouses were in primary or below level of education, accounting 72.2% and 63.8% respectively. About 64% of the interviewee had no more than five family members. More than half of the respondents (60.8%) had low incomes (less than 50,000 Myanmar kyats (MMK)). Regarding accessibility, about half of respondents (44.8%) encountered difficulty in accessing their nearest health center (that is, they experienced more than 2 hours travel there or it was not easily accessed in the rainy season). In connection with male involvement, 46.8% of the participants were provided with assistance from their husband regarding maternal care usage, such as transportation assistance, and mutual discussion for seeking and receiving maternal healthcare services.

Factors relating to maternal healthcare received during last child delivery

The average number of children that the respondents had during the study period was 2 (SD=1.4) and 34 respondents (6.8%) had 5 children and more. For just under half of the mothers (47.6%), the last child recently delivered was their first born (Table 2). Most of the mothers (76.2%) had low awareness of postnatal danger signs, including neonatal health risks. On the other hand, around a quarter (23.8%), classified as having a high level of awareness of postnatal danger signs, could name at least 3 out of 8 postpartum danger signs and 1 out of 6 neonatal danger signs. Nearly 50% perceived TBAs as skilled care givers. Only half of mothers received maternal healthcare (antenatal, intranatal and postnatal) from skilled healthcare providers, who included doctors, nurses, lady health visitors (skilled maternal care providers in rural areas) and midwives. Slightly under a quarter (23.6%) did not take antenatal care at all. Nearly two-thirds of the women in the study (64.4%) selected their home as their place of delivery. About one-third of mothers (32.6%) did not take postnatal care and just over a quarter (27.2%) received at least 4 visits (the WHO-recommended number of visits). Among the 337 respondents who took postnatal care, 83.68% received their first postnatal contact with skilled provider within 24 hours of delivery (the WHO-recommended timing of the first visit). The majority of these individuals (about 90%) received health services for both mother (84.8%) and newborns (97.3%). Regarding receipt of health education on breastfeeding and postnatal danger signs, around half of the mothers were provided with this information (breastfeeding, 48.1%; postnatal danger signs, 51.6%). Moreover, just under half of mothers could get knowledge about contraception methods (49.3%) although over three-quarters of them (75.4%) were provided with contraceptives. Almost all of them (98.8%) were given postnatal supplements, such as vitamin B1 and iron. Out of the 500 women, almost half of them (49.6%) had misconception regarding postnatal practices; these included food taboos such as avoiding the consumption of meat and some vegetables or behavioral restrictions such as avoiding going outside the delivery room within 7 days of the birth and massaging lower abdomen for the removal of impure blood.

Determinants of full PNC utilization: Bivariate analysis

Of the 500 women in this study with children under 2 years age, 126 utilized full PNC, i.e. they received at least four postnatal visits and their first visit within 24 hours after childbirth (25.20% (95%CI, 21.58-29.21)) (Table 3). The results from bivariate analysis presented as the crude odds ratio (OR) along with its 95% CI, and P-value of each variable revealed that all of the factors in the Table 3 were statistically significant associated with full PNC: these were composed of age, education attainment of respondents and their husbands, income, accessing to health center, male involvement, birth order, awareness of postnatal danger signs, acceptance of TBA, types of health care provider, number of AN visits, place of delivery and misconception regarding postnatal practices.

Determinants of full PNC utilization: Multivariable analysis

After adjusting for covariates using multivariable analysis with multivariable logistic regression implemented with GEE, it was found out that the higher the degree of school education of the mother, the larger the odds of utilizing full PNC (adjusted odds ratio (AOR), 2.16; 95% CI, 1.18-3.94) (Table 4). The rural women earning higher incomes (≥50,000 MMK) were twice as likely to receive full PNC as their counterparts earning <50,000 MMK (AOR, 2.02; 95% CI, 1.11-3.68). The participants who received support from their spouses to receive PNC were 2.19 times more likely to utilize full PNC than those who did not receive male involvement (AOR, 2.19; 95% CI, 1.02-4.69). The respondents who were knowledgeable about postnatal danger signs were two times more likely to receive full PNC than those with low awareness (AOR, 2.10; 95% CI, 1.15-3.83). Delivery of the first child (AOR, 3.26; 95% CI, 1.8-5.91) was identified as a conclusive determinant of full PNC usage. The presence of misconceptions regarding postnatal practice had a strong negative impact on the utilization of full PNC, with an AOR of 0.12 (95% CI, 0.04-0.36).