臺灣博碩士論文加值系統

Background: Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn, and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). Features of the health care delivery system may not be the only expounding factors of adequate utilization of antenatal care (ANC) among women. Other social factors such as the family structure and its environment contribute towards pregnant women’s utilization of ANC. The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. An understanding of how women in different family structure types and social groups use basic maternal health services is important towards developing and implementing maternal health care policy in the post-Millennium Development Goal era; especially in the sub-Saharan Africa where maternal mortality still remain high. Moreover, understanding the complex relationships in the continuum of care for maternal health is essential in designing and implementing a system of continuity of care towards better maternal and newborn health outcome. We also explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH.
Methods: Using Demographic and Health Surveys data of 13 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Logistic regression and Full Information Maximum Likelihood estimation procedure, which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions, was adopted using Stata 13.0 and LISREL 8.80, respectively. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model.
Results: In Kenya, family structure was associated with utilization of ANC. Also, use of antenatal care in Kenya had a positive relationship with use of delivery care (β = 0.06; OR = 1.06; 95% CI: 1.02-1.10) but not postnatal care, while delivery care was associated with postnatal care (β = 0.68; OR = 1.97; 95% CI: 1.75-2.22). Socioeconomic status was significantly related with all the elements in the continuum of care for maternal health, while barriers to delivery care and personal characteristics were only associated with use of delivery care (β = 0.34; OR = 1.40; 95% CI: 1.30-1.52) and postnatal care (β = 0.03; OR = 1.03; 95% CI: 1.01-1.05), respectively. Furthermore, in SSA, some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (β = 0.32) and to ‘adequate child’s immunization’ (β = 0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (β = 0.78) and to ‘adequate child’s immunization’ (β = 0.15) were positively associated and statistically significant at p < 0.001. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunization’ (β = -0.02) was negatively associated and significant at p < 0.001.
Conclusions: In conclusion, utilization of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunization program. Developing a referral system of continuity of care is critical in the Sustainable Development Goals era. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunization program could serve towards improving maternal and infant health outcomes and equity.

Table of contents
Dedication iv
Acknowledgements v
Abstract vi
Table of contents ix
List of tables xviii
List of figures xx
List of equations xxii
List of abbreviations xxiii
Chapter 1: Introduction 1
1.1 Background 1
1.2 Significance of the study 2
1.3 General objective of the dissertation 4
1.3.1 Specific objectives 5
1.3.1.1 Manuscript one 5
1.3.1.2 Manuscript two 5
1.3.1.3 Manuscript three 5
1.4 Structure of the dissertation 6
Chapter 2: Literature Review 7
2.1 Introduction 7
2.2 Utilization of maternal, newborn and child health care 8
2.2.1 Utilization of antenatal care 8
2.2.2 Utilization of delivery care 9
2.2.3 Utilization of postnatal care 10
2.2.4 Utilization of child’s immunization program 11
2.3 Continuum of care for MNCH 12
2.4 Conceptual framework 13
Chapter 3: Study Setting and Country’s Profile 15
3.1 Introduction 15
3.2 Country’s geopolitical, economic and health profile 15
3.2.1 Manuscript one and two 15
3.2.1.1 Kenya 15
3.2.2 Manuscript three 18
3.2.2.1 DR Congo 18
3.2.2.2 Gambia 19
3.2.2.3 Liberia 20
3.2.2.4 Mali 22
3.2.2.5 Namibia 23
3.2.2.6 Nigeria 24
3.2.2.7 Rwanda 26
3.2.2.8 Senegal 27
3.2.2.9 Sierra Leone 28
3.2.2.10 Tanzania 29
3.2.2.11 Togo 31
3.2.2.12 Zambia 32
3.3 Summary 33
Chapter 4: Detailed Methods 35
4.1 Introduction 35
4.2 Sampling strategy and sample size 36
4.3 Data collection, instrument and measures 38
4.4 Data analysis 41
4.5 Ethical consideration 42
Chapter 5: Manuscript One 43
5.1 Abstract 44
5.2 Introduction 45
5.3 Methods 48
5.3.1 Study sampling and data 48
5.3.2 Measures 50
5.3.2.1 Outcome variable 50
5.3.2.2 Explanatory variables 50
5.3.3 Data analysis 51
5.4 Results 53
5.4.1 Sample characteristics 53
5.4.2 Adequate utilization of ANC 57
5.4.3 Family structure and adequate utilization of ANC 60
5.4.4 Family structure, maternal age and SES in adequate utilization of ANC 64
5.5 Discussion 67
5.5.1 Conclusion, research and policy implication 70
5.5.2 Limitations 71
Chapter 6: Manuscript Two 72
6.1 Abstract 73
6.2 Introduction 74
6.3 Methodology 77
6.3.1 Sampling strategy 77
6.3.2 Conceptual framework 78
6.3.3 Variable definitions 79
6.3.3.1 Dependent latent variables 79
6.3.3.2 Independent latent variables 81
6.3.4 Analytical procedure 82
6.3.4.1 Handling missing data 82
6.3.4.2 Reliability and validity analysis 83
6.3.4.3 Model specification and estimation 83
6.3.4.4 Model fit criteria 86
6.3.5 Ethical consideration 87
6.4 Results 88
6.4.1 Model evaluation 92
6.4.1.1 Fit statistics 92
6.4.1.2 Measurement variables analyses 94
6.4.1.3 Multivariate structural model analysis 97
6.5 Discussion 101
6.5.1 Conclusion, policy and research implication 103
6.5.2 Limitations 104
Chapter 7: Manuscript Three 106
7.1 Abstract 107
7.2 Background 109
7.3 Methods 111
7.3.1 Study site and sampling 111
7.3.2 Conceptual framework 111
7.3.3 Data and measures 113
7.3.3.1 Outcome variables 113
7.3.3.2 Independent variables 114
7.3.4 Data analysis 115
7.3.5 Structural equations 116
7.3.6 Model evaluation 117
7.3.7 Ethical consideration 118
7.4 Results 119
7.4.1 Geographical profile and inequality in MNCH care utilization 119
7.4.2 Model evaluation 126
7.4.2.1 Determinants of MNCH care utilization measurement indicators 128
7.4.2.2 Continuum of care for MNCH measurement variables 132
7.4.3 Structural model analysis 132
7.4.3.1 Independent latent relationship to the continuum of care 135
7.4.3.2 The continuum of care for MNCH 136
7.5 Discussion 137
7.5.1 Policy and research implication 140
7.5.2 Conclusions 142
Chapter 8: Summary 143
8.1 Significant findings 143
8.1.1 Manuscript one 143
8.1.2 Manuscript two 144
8.1.3 Manuscript three 144
8.2 Policy and future research implication 146
References 148
Appendices 165
Appendix A: LISREL and SIMPLIS syntaxes used in the analysis of the structural equation model of manuscript two 165
Appendix B: Reliability analysis of measurement variables in the five latent constructs of manuscript two (n = 4,082) 167
Appendix C: The correlation and covariance matrices of the latent constructs of manuscript two 169
Appendix D: The covariance and correlation matrices of the latent constructs of manuscript three 170
Appendix E: National Yang-Ming University Ethical approval by the Institutional Review Board (IRB) 171
Appendix F: LISREL output for the relationships in the continuum of care for MHC in Kenya 172
Appendix G: LISREL output for the associations in the continuum of care for MNCH in sub-Saharan Africa 222


List of tables

Table 4 1 Sampled and number of clusters and households sampled in different sub-Saharan Africa countries 37
Table 5 1 Percentages of women aged 15-49 who had successful delivery five years prior to the survey with respect to the four basic indicators of ANC utilization, 2008-09 KDHS 54
Table 5 2 Percentages of women aged 15-49 who had successful delivery five years prior to the survey who utilized ANC adequately, by family structure, maternal age and SES, 2008-09 KDHS 58
Table 5 3 Logistic regression models predicting adequate utilization of ANC of women age 15–49 who had successful delivery five years prior to the survey, 2008-09 KDHS (n = 4,005) 61
Table 5 4 Relationships between family structure type, maternal age and SES in adequate utilization of ANC, 2008-09 KDHS (n = 4,005) 65
Table 6 1 Sample characteristics of women aged 15–49 who had a live birth in the five years preceding the survey, for the most recent birth, 2008/9 KDHS 89
Table 6 2 Multivariate standardized parameter estimates (β) and odds ratios (OR; 95% confidence interval, CI) of the measurement variables in the structural equation model, 2008/9 KDHS (n = 4,082) 95
Table 6 3 Multivariate standardized regression coefficients (β) and odds ratios (OR; confidence interval, CI) of the estimated structural equation model (Equations 3 - 5) 98
Table 7 1 Proportion of women aged 15–49, who had a live birth in the five years preceding the survey, according to maternal and child health care utilization in 12 sub-Saharan Africa countries 122
Table 7 2 Parameter estimates of measurement variables of the continuum of care for maternal and newborn health care of 12 sub Saharan Africa countries (n = 137,505) 129
Table 7 3 Standardized parameter estimates of the structural equation model (Equations 1 to 4) 134


List of figures


Figure 2 1 The conceptual framework of the relationships in the continuum of care 14
Figure 3 1 Graphical representation of the most recent maternal mortality ratio and under-5 mortality rate statistics 34
Figure 5 1 Sample size used in the study of access to maternal care in Kenya 49
Figure 6 1 Conceptual model for evaluating continuum of care for maternal health 78
Figure 6 2 Standardized parameter estimates (β coefficients) of the structural equation model estimating the continuum of care for maternal health (Refer Table 6 2 for the label name). Latent and observed variables are in oval and rectangular shapes, respectively. 93
Figure 6 3 The final structural equation model showing t-values of the significant path relationships of the continuum of care for maternal health among women aged 15–49, 2008/9 KDHS (Values in red are not significant) 100
Figure 7 1 The conceptual model of the continuum of care for maternal, newborn and child health 112
Figure 7 2 The distribution of the proportion of women who adequately utilized maternal, newborn and child health care in the 12 sub-Saharan Africa countries. A) Adequate antenatal care, B) Adequate delivery care, C) Adequate postnatal care, and D) Adequate child’s immunization. 120
Figure 7 3 The standardized parameter estimates of the continuum of care for maternal, newborn and child health care of the 12 sub-Saharan Africa countries. The oval-shaped are latent variables and the rectangle-shaped are the measurements. 127
Figure 7 4 The t-values of the structural path relationships and the correlations of the independent latent variables. The values in red are not significant. 133

List of equations


Equation 4 1 Logistic regression model 41
Equation 6 1 Structural relationship between measurements and latent variable 85
Equation 6 2 Structural relationship between two or more latent variables 85
Equation 6 3 Structural equation model of the utilization of antenatal care in Kenya 86
Equation 6 4 Structural equation model of the utilization of delivery care in Kenya 86
Equation 6 5 Structural equation model of the utilization of postnatal care in Kenya 86
Equation 7 1 Structural equation model of the utilization of antenatal care in 12 sub-Saharan Africa countries 117
Equation 7 2 Structural equation model of the utilization of delivery care in 12 sub-Saharan Africa countries 117
Equation 7 3 Structural equation model of the utilization of postnatal care in 12 sub-Saharan Africa countries 117
Equation 7 4 Structural equation model of the utilization of child’s immunization program 12 sub-Saharan Africa countries 117

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