Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study

Disparity in utilization and expectation of community-based maternal health care services among... Abstract Background Aim of this study is to assess women’s utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive. Methods A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May–September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models. Results Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women’s socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services. Conclusion Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women’s expectations on essential services during pregnancy is needed as well as strengthening community participation. community-based, disparity, expectation, maternal health care services, utilization Background Improving maternal health is one of the important issues for global health, of which appropriate utilization of antenatal care (ANC) and delivery care by skilled attendants are recommended.1–3 Although access to ANC and delivery care has been increasing worldwide, utilization of maternal health services is not being achieved in most developing countries and quality of the services remains poor.4,5 In 2015 the global maternal mortality ratio was 216 per 100 000 live births6,7 As a result, more efforts to increase the utilization of recommended maternal health services and assuring good quality of care are crucial for achieving the Sustainable Development Goals in 2030.3 Maternal health care guidelines of the essential services recommended by the World Health Organization (WHO), published in 2003, are being widely used in developing countries including Myanmar.8 The most recent update recommends that these services be included in routine clinical practice.9 In Myanmar, community-based maternal health services comprise history taking, physical examination, investigation, counseling and basic management for ANC, prevention of infection, ensuring social support and active management during the third stage of labor for delivery care.10 Bringing the maternal health services to the community was consistent with the reduction of maternal morbidity and mortality.11–13 Improving geographical accessibility of the health care services was found to be positively associated with service utilization.14–18 The utilization of services includes the measurement of essential services received.8 From previous studies, the level of service utilization is related to user’s expectations and having expectations to receive a particular service was found to be directly associated with the services being received.19–24 Disparity between the service provision and women’s expectations hinders the service uptake.25 Moreover, people’s needs and expectations for primary health care were emphasized in the World Health Report published in 2008.26 However, the expectation of women on the ANC and delivery care services has not been explicitly identified. This study thus aimed to assess the utilization and expectation of the community-based ANC and delivery care services and its disparity, and explore the associated factors with the disparity of the services. Methods Study design and setting A community-based cross-sectional study was conducted in Myanmar during May–September, 2016. Three regions (Mandalay, Magway and Bago) in the central Myanmar, where the MMR was at least 280 per 100 000 live births were purposively selected.27 One township from each of the three selected regions, namely Thabeikkyin, Myothit and Bago, was chosen based on their high maternal mortality due to severe preeclampsia/eclampsia and postpartum hemorrhage. Existing maternal health care services available in the community are similar among the three selected townships. In the rural communities, the services are provided either at Rural Health Centers and Sub-Rural Health Centers or through domiciliary care by the health care providers. One Rural Health Center covers a population of ~20 000–25 000 and is staffed by community health providers including one health assistant, one lady health visitor and approximately five midwives. One Sub-Rural Health Center is staffed by one midwife. In addition, communities have auxiliary midwives who are local residents and are trained to assist the respective midwives voluntarily in their own villages. For the urban communities, the services are provided at the primary and secondary health centers and maternal and child health centers or through the domiciliary care. Each center has at least one lady health visitor and at least three midwives on duty. The township hospital takes the curative and administrative responsibility for all health facilities in both rural and urban communities of the township.28,29 Study population, sample size and sampling All women who gave birth within the past 6 months of the date of interview, residing in the selected townships, and available during the study period were eligible. All were interviewed about the ANC services available in their community. Those who had a facility delivery or a home delivery assisted by a traditional birth attendant, relative, or neighbor, or a self-delivery, were excluded from the analysis of delivery care services. The sample size was calculated based on the lowest proportion of women who received delivery care services by a lady health visitor was found to be ~5%.30 With a 95% confidence interval and precision of 1.5%, 811 women were required. Accounting for a 45% exclusion rate and a 15% non-response rate, a total of 1736 women were thus required. A stratified two-stage sampling technique was applied. Each selected township was stratified into urban and rural areas of which wards and villages are the smallest administrative units, respectively. The wards and villages with the highest number of deliveries in the 6 months prior to data collection were considered and results showed that the number of deliveries in selected urban wards ranged from 4 to 42 and in selected rural villages ranged from 4 to 34. This distribution was similar with the other regions of the country. Purposive selection of the ward and village was based on the catchment area of the community health provider resulting in a total of 22 wards out of 39, and 230 villages out of 522 from the three townships. All eligible women from the selected wards and villages were recruited consecutively until the sample size was met leading to a maximum of 10 women per ward from Thabeikkyin and Myothit townships, 20 women per ward from Bago township, and six women per village from all townships. Data collection During data collection, an eight-member research team reached the women at the selected wards/villages. The selected women were invited to be interviewed at a place of their convenience. Study objectives were explained and consent. Pilot-tested, structured questionnaires were used for face-to-face interviews. Measurements of the variables The main outcomes were utilization and expectation of the community-based maternal health services for ANC and delivery care in the woman’s most recent pregnancy, and the disparity between the services received and services expected. Utilization of services in our study was defined as ‘receiving the essential services during ANC and delivery care from the providers in the community’ and the expectations as ‘the judgment of the women on whether or not they should receive those particular services’. Ten items of essential services performed during ANC were considered, namely, measuring body weight, recording blood pressure, clinically checking for signs of anemia, ensuring follow-up visits, birth preparedness counseling, history taking, blood testing for hemoglobin level, urine testing for protein level, iron supplementation for at least 3 months and two doses of tetanus toxoid immunization at least 1 month apart. The first five items were defined as being ‘received’ if they were performed during a minimum of four ANC visits. If the history, blood testing for hemoglobin and urine testing for protein was taken during one or more ANC visits, the woman was classified as having ‘received’ those services. Otherwise, they were defined as having ‘not received’ those services. The five items of essential services for delivery care included bringing a midwifery/auxiliary midwifery kit during the delivery as a proxy indicator of infection control, providing social support during labor, giving any injection immediately after delivery, giving any oral medication, and providing information about blood loss after delivery. Similar to ANC, each item was considered as ‘received’ or ‘not received’. Responses of ‘not sure’ or ‘could not remember’ were coded as ‘not received’. The same items for ANC and delivery care were used for measuring women’s expectation which was measured as either ‘expected’ or ‘not expected’. Responses of ‘do not know’ were coded as ‘not expected’. Agreement between services received and services expected to receive for both ANC and delivery care was determined using the prevalence adjusted bias adjusted kappa (PABAK) coefficient.31,32 Agreement was classified as poor (<0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80) and almost perfect (>0.81).33 Any service having a poor or fair agreement was defined as a service with disparity and included in multivariate multinomial logistic regression models. Disparity of services was categorized into four groups based on the agreement between the women’s utilization and expectation of the ANC/delivery care services: group 1 (received and expected), group 2 (not received, not expected), group 3 (received but not expected) and group 4 (not received but expected). Independent variables included background characteristics and obstetric information of the women, and access to ANC and delivery care. Monthly household income was categorized into two groups: lower than 103 USD versus 103 USD or above based on the 2014 Gross Domestic Product per capita of Myanmar.34 Out-of-pocket cost was defined as any costs incurred by the women after they utilized the maternal health services. The out-of-pocket cost for ANC was defined as ‘yes’ or ‘no’ due to the very small amount while for delivery care this was categorized as either ‘low’ or ‘high’ using the overall median as the cut-off value. Data management and analysis Data were entered using EpiData 3.1 and data management and analyses were done using R (R Foundation for Statistical Computing, Vienna, Austria). Background characteristics, obstetric information, and utilization and expectation of the maternal health care services were described in frequency and percentage. Independent variables which, on univariate analysis, had a P value ≤ 0.2 were included in the prototype model for the multivariate analysis of the services having a low agreement between utilization and expectation. In the multinomial logistic regression model, group 1 (received and expected maternal health services) was defined as the baseline outcome group for comparison with the other three groups. Model selection was done by assessing the P value from likelihood ratio tests with a significance level of <0.05. Results Lists containing 1767 six-month postpartum women were obtained from Township Health Officers. In total, 24 women were excluded after case review because their last delivery was actually beyond 6 months. A total of 1743 women were therefore invited to participate in the study with a response rate of 100%. All 1743 women were included in the analysis of ANC services while 973 women were included in the analysis of delivery care services. Table 1 shows the women’s background characteristics, obstetric information, and ANC and delivery care utilization status. Most (80%) of the women lived in a rural area. Approximately one-third (29%) completed primary school only or had no formal education. Approximately 40% were primiparous. Almost all (99%) had at least one ANC visit, of which most (89%) were attended by a skilled provider. More than half (60%) completed at least four ANC visits, 36% had an early ANC visit, and one-third delivered at a facility-based service. Table 1 Background and obstetric characteristics of the women and their maternal health service utilization (n = 1743) Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Monthly household income (USD) based on the woman’s estimated total family income. ANC, antenatal care. View Large Table 1 Background and obstetric characteristics of the women and their maternal health service utilization (n = 1743) Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Monthly household income (USD) based on the woman’s estimated total family income. ANC, antenatal care. View Large The percentage of women who received and expected to receive the individual ANC and delivery care services are presented in Table 2. Apart from history taking and tetanus toxoid immunization, all ANC services had <80% coverage and measuring body weight was the service that had the lowest coverage (37%). Overall, only 12% of the women received all 10 essential ANC services. In almost all services, women’s expectations were higher than their utilization of that service, the only exceptions being tetanus toxoid immunization, blood testing for hemoglobin and iron supplementation. Table 2 Percentage of women who received and expected ANC and delivery care services during their last pregnancy and childbirth   Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)    Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)  ANC, antenatal care. View Large Table 2 Percentage of women who received and expected ANC and delivery care services during their last pregnancy and childbirth   Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)    Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)  ANC, antenatal care. View Large Figure 1 shows the agreement between the services actually received and the services women expected to receive for ANC (Fig. 1A) and delivery care (Fig. 1B). The majority of services had moderate to almost perfect agreement. Services with fair agreement were blood testing for hemoglobin, urine testing for protein and iron supplementation. Fig. 1 View largeDownload slide Agreement between ANC services (A) and delivery care services (B) received and expected among the women. Fig. 1 View largeDownload slide Agreement between ANC services (A) and delivery care services (B) received and expected among the women. Factors associated with disparity of the three aforementioned ANC services that had fair agreement are shown in Table 3. Holding other variables constant and comparing to the reference groups of each independent variable, women having ANC without a skilled provider, those having fewer than four ANC visits, and women’s residing township were significantly associated with disparity in all the three ANC services. Compared to women who had early ANC, women who did not have early ANC were more likely to not receive and not expect to receive (group 2) urine testing for protein and iron supplementation. Compared to women living in urban areas, women from rural areas were more likely to not receive but expect to receive (group 4) blood test for hemoglobin and iron supplementation. Women having a primary level of education or less were more likely to not receive and not expect to receive (group 2) urine protein testing and iron supplementation. Women with a monthly household income higher than 103 USD were more likely to receive but not expect to receive (group 3) blood test for hemoglobin and urine protein testing. Table 3 Factors associated with the disparity of ANC services (reference = group 1)   Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –    Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –  Group 1: women received and expected to receive the service. Group 2: women did not receive and did not expect to receive the service. Group 3: women received but did not expect to receive the service. Group 4: women did not receive but expected to receive the service. RRR (95% CI): relative risk ratio (95% confidence interval). *Only significant values of RRR for associated factors of groups 2, 3 and 4 comparing to group 1 among three services were shown. ‘–’: non-significant RRR-not shown. ANC, antenatal care; TH, township hospital; SH, station hospital; RHC, rural health center; SC, sub-rural health center. View Large Table 3 Factors associated with the disparity of ANC services (reference = group 1)   Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –    Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –  Group 1: women received and expected to receive the service. Group 2: women did not receive and did not expect to receive the service. Group 3: women received but did not expect to receive the service. Group 4: women did not receive but expected to receive the service. RRR (95% CI): relative risk ratio (95% confidence interval). *Only significant values of RRR for associated factors of groups 2, 3 and 4 comparing to group 1 among three services were shown. ‘–’: non-significant RRR-not shown. ANC, antenatal care; TH, township hospital; SH, station hospital; RHC, rural health center; SC, sub-rural health center. View Large Women having four or more children, living far from a health facility and having no out-of-pocket costs for ANC were more likely to not receive and not expect to receive (group 2) blood testing for hemoglobin. Women having no pregnancy complications were more likely to receive but not expect to receive (group 3) blood testing for hemoglobin. Finally, women who lived close to a township hospital and women living far from a health facility were more likely to not receive but expect to receive (group 4) urine testing for protein. Discussion Main finding of this study Almost all women had at least one ANC visit attended by a skilled provider in the community. Two-thirds had at least four ANC visits but only one-third had early ANC. Less than 80% of the women received the individual essential ANC services and only one in ten women received all services. Two-thirds of the women had a non-facility delivery and the majority (71%) received all the delivery care services. Women’s expectations exceeded their utilization of nearly all services, the exceptions being tetanus toxoid immunization, blood testing for hemoglobin level and iron supplementation. Services having a disparity were blood testing for hemoglobin, urine testing for protein and iron supplementation. Factors associated with the disparity were ANC utilization, place of residence, level of education, monthly household income, parity, history of pregnancy complications, type of nearest health facility, distance to the nearest health facility and incurring out-of-pocket costs during ANC. What is already known on this topic Although ANC and skilled birth delivery is promoted to all pregnant women according to the WHO recommendations, the coverage of these two important indicators, as well as the utilization of other essential ANC services, are diverse.35–38 Most of the ANC services that the women received and expected to receive were lower than 80% in our study. The percentages of women having blood pressure measurement, and urine protein testing, and receiving iron supplementations were low in our study compared to the findings of Myanmar Demographic and Health Survey 2015–16. The differences could be due to the operational definitions used. The national survey defined service utilization for blood pressure measurement, urine protein testing, and iron supplementations if they were measured only once while in our study we used the more strict definition of at least four measurements.38 A secondary analysis of studies from 41 countries showed that the most frequently received service was measuring blood pressure followed by providing tetanus toxoid immunization, and urine testing among women who received at least four ANC visits.4 What is this study adds Although the percentage of women’s expectations on most of the ANC services was slightly higher than the services they received, both services received and expected were below the 80%. To date, no study has explored women’s expectations on maternal health care services received and the disparity between the services they received and those they expected. Two previous studies, one investigating antibiotic prescriptions and another among women undergoing cesarean section, showed that the service (antibiotics prescription or cesarean section) was influenced by the patient’s expectation.20,23 According to a literature review on women’s satisfaction with maternal health care from developing countries,39 the perception of good care related to a woman’s expectation is one of the determinants of satisfaction. As a result, more efforts to improve women’s awareness on the value of the services, empowering them to expect and request the required services, and improving health providers’ perceptions of the women’s right to receive the quality services are urgently required in Myanmar. The reasons for the low service utilization and service with disparity—blood test for hemoglobin, urine test for protein and iron supplementation—were not assessed in our study and it is recommended that this be further investigated in future studies for better policy planning. These may be explained probably by a shortage of supply in some seasons, and high workloads of the health providers and adherence to the practice guidelines previously reported.28,40,41 Our study showed that women with a higher than average household income also influenced the disparity of services, particularly in women who received the services but did not expect to receive them. An explanation for this finding is unknown. Previous studies measured only utilization, not expectation, and showed a better chance of urban women assessing the maternal health care services and less ANC visits among higher parity women.42–44 Lower frequency of ANC visits may lead to insufficient service uptake.4 Complications during pregnancy with disparity of blood testing for hemoglobin may be explained by the possibility of being referred to the higher level and therefore the women may have received the service elsewhere. Limitations of this study Firstly, all information was based on the women’s own responses, and thus recall bias was unavoidable. A 6-month recall period is unlikely to cause serious bias, although the level of details on the services received may be a challenge for some women to recall. Unfortunately, we did not validate the women’s responses with their medical records. However, responses of ‘not sure’ or ‘could not remember’ were low (<1%), thus, we believe recall bias was minimal in this study. Secondly, consecutive sampling used in this study may have resulted in selection bias. Thirdly, this study focused community-based services, therefore, generalization of the findings cannot be made throughout Myanmar. However, non-facility delivery services are used by more than half of pregnant women in Myanmar.38 Fourthly, women’s knowledge and satisfaction of maternal health services were not measured in this study. Finally, the workload of services provided in the community should be further explored as it is important to the quality of care. Ethical clearance Ethical approval was granted by the Ethics Review Committees of the Department of Medical Research, Myanmar (12/Ethics/DMR/2016) and Prince of Songkla University, Thailand (REC No. 58-355-18-5). Authors’ contributions All authors conceived and designed the study. TT and TL participated in the concept of study design, data collection, data analysis, interpretation of the data and preparation of the article. EM involved in the data analysis and reviewed the article. All authors approved of the final version to be published. Conflict of interest All authors have declared that they have no conflict of interest. Acknowledgements This study was a part of the thesis of the first author to fulfill the requirement of the Doctoral degree in Epidemiology at Prince of Songkla University. Fellowship grant is supported by the World Health Organization (WHO), the Special Program on Human Reproduction (HRP), and the Discipline of Excellence in Epidemiology (Phase 2): Asia Mentoring Institute. We express our grateful thanks to the women who sacrificed their time to participate in this study. We acknowledge the support of Township Medical Officers and the Director of the Maternal and Reproductive Health Section, Department of Public Health. Funding The research was supported by the fund from the Prince of Songkla University, Hat Yai, Thailand through the Discipline of Excellence in Epidemiology (Phase 2): Asia Mentoring Institute granted to the Epidemiology Unit, Faculty of Medicine and the Graduate School Dissertation Funding for the PhD Thesis. References 1 World Health Organization. The World Health Report 2005: Make Every Mother and Child Count . Geneva: World Health Organization, 2005. http://www.who.int/whr/2005/whr2005_en.pdf?ua=1. 2 Adam T, Lim SS, Mehta S et al.  . Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. Br Med J  2005; 331( 7525): 1107. Google Scholar CrossRef Search ADS   3 World Health Organization. Maternal Mortality [Internet] . Geneva: World Health Organization, 2016. [cited 2017 April 6]. Available from: 2(2): 173–81. 4 Hodgins S, D’Agostino A. The quality–coverage gap in antenatal care: toward better measurement of effective coverage. Glob Health Sci Pract  2014; 2( 2): 173– 81. Google Scholar CrossRef Search ADS PubMed  5 Kyei NNA, Chansa C, Gabrysch S. Quality of antenatal care in Zambia: a national assessment. BMC Pregnancy Childbirth  2012; 12: 151. http://www.biomedcentral.com/1471-2393/12/151. Google Scholar CrossRef Search ADS PubMed  6 WHO, UNICEF, UNFPA, Word Bank. Trends in Maternal Mortality: 1990 to 2015 . Geneva: World Health Organization, 2015. http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf. 7 Alkema L, Chou D, Hogan D et al.  . Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet  2016; 387( 10017): 462– 74. Google Scholar CrossRef Search ADS PubMed  8 World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice . 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Available from https://www.ssatp.org/sites/ssatp/files/pdfs/Topics/gender/259010REPLACEM10082135362401PUBLIC1%5B2%5D.pdf. (Health, nutrition, and population series). 13 Berhan Y, Berhan A. Skilled health personnel attended delivery as a proxy indicator for maternal and perinatal mortality: a systematic review. Ethiop J Health Sci  2014; 24: 69– 80. Google Scholar CrossRef Search ADS PubMed  14 Knowlton AR, Hoover DR, Chung S et al.  . Access to medical care and service utilization among injection drug users with HIV/AIDS. Drug Alcohol Depend  2001; 64( 1): 55– 62. Google Scholar CrossRef Search ADS PubMed  15 Tsegay Y, Gebrehiwot T, Goicolea I et al.  . Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study. Int J Equity Health  2013; 12( 1): 1. Google Scholar CrossRef Search ADS PubMed  16 Kawakatsu Y, Sugishita T, Oruenjo K et al.  . Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study. BMC Pregnancy Childbirth  2014; 14: 265. Google Scholar CrossRef Search ADS PubMed  17 Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health  2011; 10( 1): 1. Google Scholar CrossRef Search ADS PubMed  18 Sein KK. Maternal health care utilization among ever married youths in Kyimyindaing Township, Myanmar. Matern Child Health J  2012; 16( 5): 1021– 30. Google Scholar CrossRef Search ADS PubMed  19 Bowling A, Rowe G, Lambert N et al.  . The measurement of patients’ expectations for health care: a review and psychometric testing of a measure of patients’ expectations. Health Technol Assess [Internet]  2012; 16( 30): i–xii, 1–509. https://www.journalslibrary.nihr.ac.uk/hta/hta16300/. 20 Eilat-Tsanani S, Tabenkin H, Chazan B et al.  . Acute cough: the use of antibiotics and health care services in an urban health centre in Israel. Eur J Gen Pract  2013; 19( 2): 92– 8. Google Scholar CrossRef Search ADS PubMed  21 Coenen S, Francis N, Kelly M et al.  . Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients with acute cough. Palaniyar N, editor. PLoS One  2013; 8( 10): e76691. Google Scholar CrossRef Search ADS PubMed  22 Wong CKM, Liu Z, Butler CC et al.  . Help-seeking and antibiotic prescribing for acute cough in a Chinese primary care population: a prospective multicentre observational study. NPJ Prim Care Respir Med  2016; 26( 1): 5080. 23 MacKenzie IZ, Cooke I, Annan B. Indications for caesarean section in a consultant obstetric unit over three decades. J Obstet Gynaecol  2003; 23( 3): 233– 8. Google Scholar CrossRef Search ADS PubMed  24 Figaro MK, Williams-Russo P, Allegrante JP. Expectation and outlook: the impact of patient preference on arthritis care among African Americans. J Ambulatory Care Manage  2005; 28( 1): 41– 8. Google Scholar CrossRef Search ADS PubMed  25 Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med  2013; 10( 1): e1001373. Google Scholar CrossRef Search ADS PubMed  26 Van Lerberghe W. The World Health Report 2008: Primary Health Care: Now More Than Ever [Internet] . Geneva: World Health Organization, 2008. Available from. http://www.who.int/whr/2008/whr08_en.pdf. [cited 2017 Apr 26]. 27 Ministry of Labour, Immigration and Population, UNFPA. The 2014 Myanmar Population and Housing Census, THEMATIC REPORT ON MORTALITY [Internet]. 2016. Report No.: Census Report Volume 4-B. http://www.themimu.info/sites/themimu.info/files/documents/Report_Thematic_Report_On_Mortality_-_Census_Report_V4-B_DOP_Sep2016_ENG.pdf 28 Tin N, Phyo MT, Sein TT et al.  . Are We Overburdened in Rural Area? Voices of Midwives [Internet] . Nay Pyi Taw: Department of Health, Department of Medical Research (Lower Myanmar), 2007. https://www.unops.org/ApplyBO/File.aspx/Attachment%204%20Mid%20Wife%20Burden%20Study.pdf?AttachmentID=31f0ca87-5f77-4867-8723-7b303ea5d283. Available from. 29 Ministry of Health. Health in Myanmar [Internet]. Nay Pyi Taw: Ministry of Health, 2011. http://mohs.gov.mm/content/publication/list?category=Health%20in%20Myanmar&pagenumber=1&pagesize=40. 30 Ministry of National Planning and Economic Development and Ministry of Health, Myanmar. Myanmar Multiple Indicator Cluster Survey 2009–2010 Final Report. [Internet]. Nay Pyi Taw: Ministry of Health, Myanmar, 2011. https://www.unicef.org/myanmar/MICS_Myanmar_Report_2009-10.pdf. 31 Hayes KW, Petersen CM. Reliability of assessing end-feel and pain and resistance sequence in subjects with painful shoulders and knees. J Orthop Sports Phys Ther  2001; 31( 8): 432– 45. Google Scholar CrossRef Search ADS PubMed  32 Julius S, Chris CW. The Kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther  2005; 85( 3): 257– 68. Google Scholar PubMed  33 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics  1977; 33( 1): 159– 74. Google Scholar CrossRef Search ADS PubMed  34 UNdata | country profile | Myanmar [Internet]. [cited 2017 April 28]. http://data.un.org/CountryProfile.aspx?crName=myanmar 35 Tran TK, Nguyen CT, Nguyen HD et al.  . Urban-rural disparities in antenatal care utilization: a study of two cohorts of pregnant women in Vietnam. BMC Health Serv Res  2011; 11( 1): 120. Google Scholar CrossRef Search ADS PubMed  36 Halle-Ekane GE, Obinchemti TE, Nzang J-LN et al.  . Assessment of the content and utilization of antenatal care services in a rural community in cameroon: a cross-sectional study. Open J Obstet Gynecol  2014; 4( 14): 846– 56. Google Scholar CrossRef Search ADS   37 World Health Organization. World Health Statistics 2014 [Internet] . Geneva: World Health Organization, 2005. Available from. http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf. 38 Ministry of Health and Sports (MoHS) and ICF. Myanmar Demographic and Health Survey 2015–16 [Internet]. Nay Pyi Taw: Ministry of Health and Sports and ICF, 2017. https://dhsprogram.com/pubs/pdf/FR324/FR324.pdf. 39 Srivastava A, Avan BI, Rajbangshi P et al.  . Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy Childbirth  2015; 15: 97. Google Scholar CrossRef Search ADS PubMed  40 Ministry of Health, UNFPA. 2015 Health Facility Assessment on Reproductive Health Commodities and Services [Internet]. 2015. http://myanmar.unfpa.org/sites/default/files/pub-pdf/2015%20Health%20Facility%20Assessment%20on%20RHCS.pdf 41 Amoakoh-Coleman M, Agyepong IA, Kayode GA et al.  . Public health facility resource availability and provider adherence to first antenatal guidelines in a low resource setting in Accra, Ghana. BMC Health Serv Res  2016; 16( 1): 505. Google Scholar CrossRef Search ADS PubMed  42 Bbaale E. Factors influencing the utilisation of antenatal care content in Uganda. Australas Med J  2011; 4( 9): 516– 26. Google Scholar CrossRef Search ADS PubMed  43 Thin Zaw PP, Liabsuetrakul T, Htay TT et al.  . Equity of access to reproductive health services among youths in resource-limited suburban communities of Mandalay City, Myanmar. BMC Health Serv Res  2012; 12: 458. Google Scholar CrossRef Search ADS PubMed  44 Rahman A, Nisha MK, Begum T et al.  . Trends, determinants and inequities of 4(+) ANC utilisation in Bangladesh. J Health Popul Nutr  2017; 36( 1): 2. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. 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Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study

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Abstract

Abstract Background Aim of this study is to assess women’s utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive. Methods A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May–September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models. Results Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women’s socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services. Conclusion Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women’s expectations on essential services during pregnancy is needed as well as strengthening community participation. community-based, disparity, expectation, maternal health care services, utilization Background Improving maternal health is one of the important issues for global health, of which appropriate utilization of antenatal care (ANC) and delivery care by skilled attendants are recommended.1–3 Although access to ANC and delivery care has been increasing worldwide, utilization of maternal health services is not being achieved in most developing countries and quality of the services remains poor.4,5 In 2015 the global maternal mortality ratio was 216 per 100 000 live births6,7 As a result, more efforts to increase the utilization of recommended maternal health services and assuring good quality of care are crucial for achieving the Sustainable Development Goals in 2030.3 Maternal health care guidelines of the essential services recommended by the World Health Organization (WHO), published in 2003, are being widely used in developing countries including Myanmar.8 The most recent update recommends that these services be included in routine clinical practice.9 In Myanmar, community-based maternal health services comprise history taking, physical examination, investigation, counseling and basic management for ANC, prevention of infection, ensuring social support and active management during the third stage of labor for delivery care.10 Bringing the maternal health services to the community was consistent with the reduction of maternal morbidity and mortality.11–13 Improving geographical accessibility of the health care services was found to be positively associated with service utilization.14–18 The utilization of services includes the measurement of essential services received.8 From previous studies, the level of service utilization is related to user’s expectations and having expectations to receive a particular service was found to be directly associated with the services being received.19–24 Disparity between the service provision and women’s expectations hinders the service uptake.25 Moreover, people’s needs and expectations for primary health care were emphasized in the World Health Report published in 2008.26 However, the expectation of women on the ANC and delivery care services has not been explicitly identified. This study thus aimed to assess the utilization and expectation of the community-based ANC and delivery care services and its disparity, and explore the associated factors with the disparity of the services. Methods Study design and setting A community-based cross-sectional study was conducted in Myanmar during May–September, 2016. Three regions (Mandalay, Magway and Bago) in the central Myanmar, where the MMR was at least 280 per 100 000 live births were purposively selected.27 One township from each of the three selected regions, namely Thabeikkyin, Myothit and Bago, was chosen based on their high maternal mortality due to severe preeclampsia/eclampsia and postpartum hemorrhage. Existing maternal health care services available in the community are similar among the three selected townships. In the rural communities, the services are provided either at Rural Health Centers and Sub-Rural Health Centers or through domiciliary care by the health care providers. One Rural Health Center covers a population of ~20 000–25 000 and is staffed by community health providers including one health assistant, one lady health visitor and approximately five midwives. One Sub-Rural Health Center is staffed by one midwife. In addition, communities have auxiliary midwives who are local residents and are trained to assist the respective midwives voluntarily in their own villages. For the urban communities, the services are provided at the primary and secondary health centers and maternal and child health centers or through the domiciliary care. Each center has at least one lady health visitor and at least three midwives on duty. The township hospital takes the curative and administrative responsibility for all health facilities in both rural and urban communities of the township.28,29 Study population, sample size and sampling All women who gave birth within the past 6 months of the date of interview, residing in the selected townships, and available during the study period were eligible. All were interviewed about the ANC services available in their community. Those who had a facility delivery or a home delivery assisted by a traditional birth attendant, relative, or neighbor, or a self-delivery, were excluded from the analysis of delivery care services. The sample size was calculated based on the lowest proportion of women who received delivery care services by a lady health visitor was found to be ~5%.30 With a 95% confidence interval and precision of 1.5%, 811 women were required. Accounting for a 45% exclusion rate and a 15% non-response rate, a total of 1736 women were thus required. A stratified two-stage sampling technique was applied. Each selected township was stratified into urban and rural areas of which wards and villages are the smallest administrative units, respectively. The wards and villages with the highest number of deliveries in the 6 months prior to data collection were considered and results showed that the number of deliveries in selected urban wards ranged from 4 to 42 and in selected rural villages ranged from 4 to 34. This distribution was similar with the other regions of the country. Purposive selection of the ward and village was based on the catchment area of the community health provider resulting in a total of 22 wards out of 39, and 230 villages out of 522 from the three townships. All eligible women from the selected wards and villages were recruited consecutively until the sample size was met leading to a maximum of 10 women per ward from Thabeikkyin and Myothit townships, 20 women per ward from Bago township, and six women per village from all townships. Data collection During data collection, an eight-member research team reached the women at the selected wards/villages. The selected women were invited to be interviewed at a place of their convenience. Study objectives were explained and consent. Pilot-tested, structured questionnaires were used for face-to-face interviews. Measurements of the variables The main outcomes were utilization and expectation of the community-based maternal health services for ANC and delivery care in the woman’s most recent pregnancy, and the disparity between the services received and services expected. Utilization of services in our study was defined as ‘receiving the essential services during ANC and delivery care from the providers in the community’ and the expectations as ‘the judgment of the women on whether or not they should receive those particular services’. Ten items of essential services performed during ANC were considered, namely, measuring body weight, recording blood pressure, clinically checking for signs of anemia, ensuring follow-up visits, birth preparedness counseling, history taking, blood testing for hemoglobin level, urine testing for protein level, iron supplementation for at least 3 months and two doses of tetanus toxoid immunization at least 1 month apart. The first five items were defined as being ‘received’ if they were performed during a minimum of four ANC visits. If the history, blood testing for hemoglobin and urine testing for protein was taken during one or more ANC visits, the woman was classified as having ‘received’ those services. Otherwise, they were defined as having ‘not received’ those services. The five items of essential services for delivery care included bringing a midwifery/auxiliary midwifery kit during the delivery as a proxy indicator of infection control, providing social support during labor, giving any injection immediately after delivery, giving any oral medication, and providing information about blood loss after delivery. Similar to ANC, each item was considered as ‘received’ or ‘not received’. Responses of ‘not sure’ or ‘could not remember’ were coded as ‘not received’. The same items for ANC and delivery care were used for measuring women’s expectation which was measured as either ‘expected’ or ‘not expected’. Responses of ‘do not know’ were coded as ‘not expected’. Agreement between services received and services expected to receive for both ANC and delivery care was determined using the prevalence adjusted bias adjusted kappa (PABAK) coefficient.31,32 Agreement was classified as poor (<0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80) and almost perfect (>0.81).33 Any service having a poor or fair agreement was defined as a service with disparity and included in multivariate multinomial logistic regression models. Disparity of services was categorized into four groups based on the agreement between the women’s utilization and expectation of the ANC/delivery care services: group 1 (received and expected), group 2 (not received, not expected), group 3 (received but not expected) and group 4 (not received but expected). Independent variables included background characteristics and obstetric information of the women, and access to ANC and delivery care. Monthly household income was categorized into two groups: lower than 103 USD versus 103 USD or above based on the 2014 Gross Domestic Product per capita of Myanmar.34 Out-of-pocket cost was defined as any costs incurred by the women after they utilized the maternal health services. The out-of-pocket cost for ANC was defined as ‘yes’ or ‘no’ due to the very small amount while for delivery care this was categorized as either ‘low’ or ‘high’ using the overall median as the cut-off value. Data management and analysis Data were entered using EpiData 3.1 and data management and analyses were done using R (R Foundation for Statistical Computing, Vienna, Austria). Background characteristics, obstetric information, and utilization and expectation of the maternal health care services were described in frequency and percentage. Independent variables which, on univariate analysis, had a P value ≤ 0.2 were included in the prototype model for the multivariate analysis of the services having a low agreement between utilization and expectation. In the multinomial logistic regression model, group 1 (received and expected maternal health services) was defined as the baseline outcome group for comparison with the other three groups. Model selection was done by assessing the P value from likelihood ratio tests with a significance level of <0.05. Results Lists containing 1767 six-month postpartum women were obtained from Township Health Officers. In total, 24 women were excluded after case review because their last delivery was actually beyond 6 months. A total of 1743 women were therefore invited to participate in the study with a response rate of 100%. All 1743 women were included in the analysis of ANC services while 973 women were included in the analysis of delivery care services. Table 1 shows the women’s background characteristics, obstetric information, and ANC and delivery care utilization status. Most (80%) of the women lived in a rural area. Approximately one-third (29%) completed primary school only or had no formal education. Approximately 40% were primiparous. Almost all (99%) had at least one ANC visit, of which most (89%) were attended by a skilled provider. More than half (60%) completed at least four ANC visits, 36% had an early ANC visit, and one-third delivered at a facility-based service. Table 1 Background and obstetric characteristics of the women and their maternal health service utilization (n = 1743) Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Monthly household income (USD) based on the woman’s estimated total family income. ANC, antenatal care. View Large Table 1 Background and obstetric characteristics of the women and their maternal health service utilization (n = 1743) Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Information  N (%)  Residence   Urban  344 (19.7)   Rural  1399 (80.3)  Age (years)   <20  115 (6.6)   20–34  1303 (74.8)   ≥35  325 (18.6)  Education   Primary school or less  502 (28.8)   Middle school  898 (51.5)   High school or above  343 (19.7)  Monthly household income (USD)   <103  678 (38.9)   ≥103  1065 (61.1)  Parity   1  675 (38.7)   2–4  918 (52.7)   >4  150 (8.6)  Pregnancy complications   No  1489 (85.4)   Yes  254 (14.6)  Delivery complications   No  1631 (93.6)   Yes  112 (6.4)  Type of nearest health center   Township hospital  218 (12.5)   Station hospital  70 (4.0)   Rural health center  363 (20.8)   Sub-rural health center  1092 (62.7)  Distance to the nearest health facility (km)   ≤1.5  868 (49.8)   1.5–5  752 (43.1)   >5  123 (7.1)  Out-of-pocket cost for ANC (USD)   No  1013 (58.1)   Yes  730 (41.9)  Out-of-pocket cost for delivery care (USD)   Low (<30)  892 (51.2)   High (≥30)  851 (48.8)  ANC attended by a skilled provider   No  194 (11.1)   Yes  1549 (88.9)  ANC4+   No  704 (40.4)   Yes  1039 (59.6)  Early ANC (≤12 weeks)   No  1108 (63.6)   Yes  635 (36.4)  Delivery place   Non-facility delivery  1127 (64.7)   Facility delivery  616 (35.3)  Monthly household income (USD) based on the woman’s estimated total family income. ANC, antenatal care. View Large The percentage of women who received and expected to receive the individual ANC and delivery care services are presented in Table 2. Apart from history taking and tetanus toxoid immunization, all ANC services had <80% coverage and measuring body weight was the service that had the lowest coverage (37%). Overall, only 12% of the women received all 10 essential ANC services. In almost all services, women’s expectations were higher than their utilization of that service, the only exceptions being tetanus toxoid immunization, blood testing for hemoglobin and iron supplementation. Table 2 Percentage of women who received and expected ANC and delivery care services during their last pregnancy and childbirth   Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)    Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)  ANC, antenatal care. View Large Table 2 Percentage of women who received and expected ANC and delivery care services during their last pregnancy and childbirth   Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)    Received N (%)  Expected N (%)  ANC (n = 1743)   Medical history  1573 (90.2)  1639 (94.0)   Tetanus toxoid immunization  1497 (85.9)  1200 (68.8)   Blood test for hemoglobin  1283 (73.6)  1219 (69.9)   Iron supplementation for at least 3 months  1109 (63.6)  1081 (62.0)   Blood pressure measurement  954 (54.7)  976 (56.0)   Ensuring follow-up visit  954 (54.7)  967 (55.5)   Urine test for protein  880 (50.5)  1186 (68.0)   Counseling on birth preparedness  823 (47.2)  886 (50.8)   Checking anemia clinically  696 (39.9)  842 (48.3)   Body weight measurement  644 (36.9)  817 (46.9)   All ANC services  207 (11.9)  257 (14.7)  Delivery care (n = 973)   Brought a midwifery kit  967 (99.4)  960 (98.7)   Having social support during labor pain  959 (98.6)  957 (98.4)   Received oral medication after delivery  880 (90.4)  894 (91.9)   Received information about blood loss  864 (88.8)  920 (94.6)   Received any injection immediately after delivery  784 (80.6)  813 (83.6)   All delivery care services  742 (76.3)  627 (64.4)  ANC, antenatal care. View Large Figure 1 shows the agreement between the services actually received and the services women expected to receive for ANC (Fig. 1A) and delivery care (Fig. 1B). The majority of services had moderate to almost perfect agreement. Services with fair agreement were blood testing for hemoglobin, urine testing for protein and iron supplementation. Fig. 1 View largeDownload slide Agreement between ANC services (A) and delivery care services (B) received and expected among the women. Fig. 1 View largeDownload slide Agreement between ANC services (A) and delivery care services (B) received and expected among the women. Factors associated with disparity of the three aforementioned ANC services that had fair agreement are shown in Table 3. Holding other variables constant and comparing to the reference groups of each independent variable, women having ANC without a skilled provider, those having fewer than four ANC visits, and women’s residing township were significantly associated with disparity in all the three ANC services. Compared to women who had early ANC, women who did not have early ANC were more likely to not receive and not expect to receive (group 2) urine testing for protein and iron supplementation. Compared to women living in urban areas, women from rural areas were more likely to not receive but expect to receive (group 4) blood test for hemoglobin and iron supplementation. Women having a primary level of education or less were more likely to not receive and not expect to receive (group 2) urine protein testing and iron supplementation. Women with a monthly household income higher than 103 USD were more likely to receive but not expect to receive (group 3) blood test for hemoglobin and urine protein testing. Table 3 Factors associated with the disparity of ANC services (reference = group 1)   Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –    Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –  Group 1: women received and expected to receive the service. Group 2: women did not receive and did not expect to receive the service. Group 3: women received but did not expect to receive the service. Group 4: women did not receive but expected to receive the service. RRR (95% CI): relative risk ratio (95% confidence interval). *Only significant values of RRR for associated factors of groups 2, 3 and 4 comparing to group 1 among three services were shown. ‘–’: non-significant RRR-not shown. ANC, antenatal care; TH, township hospital; SH, station hospital; RHC, rural health center; SC, sub-rural health center. View Large Table 3 Factors associated with the disparity of ANC services (reference = group 1)   Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –    Blood test for hemoglobin  Urine test for protein  Iron supplementation  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  Group 2  Group 3  Group 4  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  RRR* (95% CI)  Skilled ANC provider   No versus yes  3.1 (2.1,4.7)  0.8 (0.5,1.4)  1.7 (1.1,2.7)  1.7 (1.1,2.4)  0.6 (0.3,1.2)  1.1 (0.8,1.7)  1.7 (1.1,2.5)  0.7 (0.4,1.1)  0.9 (0.6,1.4)  At least four ANC visits   No versus yes  2.5 (1.8,3.4)  0.9 (0.7,1.2)  1.9 (1.4,2.5)  1.7 (1.3,2.2)  1.0 (0.7,1.4)  1.7 (1.4,2.2)  4.1 (3.1,5.5)  1.2 (0.9,1.6)  3.0 (2.3,4.0)  Early ANC   No versus yes  –  –  –  1.6 (1.2,2.2)  0.8 (0.6,1.2)  1.2 (0.9,1.6)  2.0 (1.5,2.8)  1.0 (0.8,1.4)  1.6 (1.2,2.1)  Township   Thabeikkyin versus Myothit  1.2 (0.8,2.0)  2.0 (1.3,3.1)  1.1 (0.7,1.6)  1.4 (0.9,2.0)  2.4 (1.3,4.3)  1.0 (0.7,1.4)  1.8 (1.2,2.6)  0.5 (0.3,0.7)  2.5 (1.6,3.8)   Bago versus Myothit  1.7 (1.1,2.6)  1.9 (1.3,2.8)  0.9 (0.6,1.3)  1.3 (0.9,1.8)  2.6 (1.5,4.3)  0.8 (0.6,1.1)  1.3 (0.9,2.0)  0.6 (0.5,0.9)  1.6 (1.1,2.4)  Residence   Rural versus urban  2.0 (1.2,3.2)  1.8 (1.3,2.7)  2.8 (1.7,4.8)  –  –  –  1.5 (1.0,2.1)  0.8 (0.5,1.2)  2.0 (1.4,2.9)  Education level   ≤Primary versus ≥high school  –  –  –  1.9 (1.3,2.8)  1.4 (0.8,2.3)  1.0 (0.7,1.4)  2.8 (1.8,4.5)  2.0 (1.4,3.0)  1.1 (0.8,1.7)   Middle versus ≥high school  –  –  –  1.4 (1.0,2)  1.3 (0.8,2.1)  1.3 (0.9,1.78)  2.0 (1.3,3.1)  1.3 (0.9,1.9)  1.0 (0.7,1.5)  Household income   ≥103 versus <103  1.2 (0.9,1.7)  2.0 (1.5,2.6)  1.0 (0.7,1.3)  1.3 (1.0,1.8)  1.8 (1.2,2.7)  1.1 (0.8,1.4)  –  –  –  Parity   2–4 versus 1  1.4 (1.0,1.9)  1.0 (0.7,1.3)  1.2 (0.9,1.6)  –  –  –  –  –  –    > 4 versus 1  2.6 (1.5,4.4)  1.6 (1.0,2.5)  1.1 (0.6,1.9)  –  –  –  –  –  –  Pregnancy complication                   No versus yes  1.5 (0.9,2.4)  2.0 (1.3,3.1)  1.0 (0.7,1.4)  –  –  –  –  –  –  Type of nearest health facility   SC versus RHC  –  –  –  1.3 (0.9,1.8)  0.8 (0.5,1.2)  1.3 (0.9,1.7)  –  –  –   SH versus RHC  –  –  –  0.9 (0.5,2.0)  0.3 (0.1,1.2)  1.5 (0.8,2.9)  –  –  –   TH versus RHC  –  –  –  1.2 (0.8,2.0)  0.5 (0.3,1.0)  1.7 (1.1,2.7)  –  –  –  Distance to nearest health facility (km)   1.5–5 versus < 1.5  1.4 (1.0,2.0)  1.4 (1.1,1.9)  1.2 (0.9,1.6)  1.3 (1.0,1.7)  1.4 (1.0,2.1)  1.3 (1.0,1.6)  –  –  –   ≥ 6 versus < 1.5  2.6 (1.5,4.7)  1.5 (0.9,2.7)  1.9 (1.1,3.2)  1.6 (0.9,2.7)  1.4 (0.7,3.2)  2.3 (1.4,3.7)  –  –  –  Out-of-pocket cost for ANC visit   No versus yes  2.0 (1.4,3.0)  1.3 (1.0,1.7)  1.5 (1.0,2.1)  –  –  –  –  –  –  Group 1: women received and expected to receive the service. Group 2: women did not receive and did not expect to receive the service. Group 3: women received but did not expect to receive the service. Group 4: women did not receive but expected to receive the service. RRR (95% CI): relative risk ratio (95% confidence interval). *Only significant values of RRR for associated factors of groups 2, 3 and 4 comparing to group 1 among three services were shown. ‘–’: non-significant RRR-not shown. ANC, antenatal care; TH, township hospital; SH, station hospital; RHC, rural health center; SC, sub-rural health center. View Large Women having four or more children, living far from a health facility and having no out-of-pocket costs for ANC were more likely to not receive and not expect to receive (group 2) blood testing for hemoglobin. Women having no pregnancy complications were more likely to receive but not expect to receive (group 3) blood testing for hemoglobin. Finally, women who lived close to a township hospital and women living far from a health facility were more likely to not receive but expect to receive (group 4) urine testing for protein. Discussion Main finding of this study Almost all women had at least one ANC visit attended by a skilled provider in the community. Two-thirds had at least four ANC visits but only one-third had early ANC. Less than 80% of the women received the individual essential ANC services and only one in ten women received all services. Two-thirds of the women had a non-facility delivery and the majority (71%) received all the delivery care services. Women’s expectations exceeded their utilization of nearly all services, the exceptions being tetanus toxoid immunization, blood testing for hemoglobin level and iron supplementation. Services having a disparity were blood testing for hemoglobin, urine testing for protein and iron supplementation. Factors associated with the disparity were ANC utilization, place of residence, level of education, monthly household income, parity, history of pregnancy complications, type of nearest health facility, distance to the nearest health facility and incurring out-of-pocket costs during ANC. What is already known on this topic Although ANC and skilled birth delivery is promoted to all pregnant women according to the WHO recommendations, the coverage of these two important indicators, as well as the utilization of other essential ANC services, are diverse.35–38 Most of the ANC services that the women received and expected to receive were lower than 80% in our study. The percentages of women having blood pressure measurement, and urine protein testing, and receiving iron supplementations were low in our study compared to the findings of Myanmar Demographic and Health Survey 2015–16. The differences could be due to the operational definitions used. The national survey defined service utilization for blood pressure measurement, urine protein testing, and iron supplementations if they were measured only once while in our study we used the more strict definition of at least four measurements.38 A secondary analysis of studies from 41 countries showed that the most frequently received service was measuring blood pressure followed by providing tetanus toxoid immunization, and urine testing among women who received at least four ANC visits.4 What is this study adds Although the percentage of women’s expectations on most of the ANC services was slightly higher than the services they received, both services received and expected were below the 80%. To date, no study has explored women’s expectations on maternal health care services received and the disparity between the services they received and those they expected. Two previous studies, one investigating antibiotic prescriptions and another among women undergoing cesarean section, showed that the service (antibiotics prescription or cesarean section) was influenced by the patient’s expectation.20,23 According to a literature review on women’s satisfaction with maternal health care from developing countries,39 the perception of good care related to a woman’s expectation is one of the determinants of satisfaction. As a result, more efforts to improve women’s awareness on the value of the services, empowering them to expect and request the required services, and improving health providers’ perceptions of the women’s right to receive the quality services are urgently required in Myanmar. The reasons for the low service utilization and service with disparity—blood test for hemoglobin, urine test for protein and iron supplementation—were not assessed in our study and it is recommended that this be further investigated in future studies for better policy planning. These may be explained probably by a shortage of supply in some seasons, and high workloads of the health providers and adherence to the practice guidelines previously reported.28,40,41 Our study showed that women with a higher than average household income also influenced the disparity of services, particularly in women who received the services but did not expect to receive them. An explanation for this finding is unknown. Previous studies measured only utilization, not expectation, and showed a better chance of urban women assessing the maternal health care services and less ANC visits among higher parity women.42–44 Lower frequency of ANC visits may lead to insufficient service uptake.4 Complications during pregnancy with disparity of blood testing for hemoglobin may be explained by the possibility of being referred to the higher level and therefore the women may have received the service elsewhere. Limitations of this study Firstly, all information was based on the women’s own responses, and thus recall bias was unavoidable. A 6-month recall period is unlikely to cause serious bias, although the level of details on the services received may be a challenge for some women to recall. Unfortunately, we did not validate the women’s responses with their medical records. However, responses of ‘not sure’ or ‘could not remember’ were low (<1%), thus, we believe recall bias was minimal in this study. Secondly, consecutive sampling used in this study may have resulted in selection bias. Thirdly, this study focused community-based services, therefore, generalization of the findings cannot be made throughout Myanmar. However, non-facility delivery services are used by more than half of pregnant women in Myanmar.38 Fourthly, women’s knowledge and satisfaction of maternal health services were not measured in this study. Finally, the workload of services provided in the community should be further explored as it is important to the quality of care. Ethical clearance Ethical approval was granted by the Ethics Review Committees of the Department of Medical Research, Myanmar (12/Ethics/DMR/2016) and Prince of Songkla University, Thailand (REC No. 58-355-18-5). Authors’ contributions All authors conceived and designed the study. TT and TL participated in the concept of study design, data collection, data analysis, interpretation of the data and preparation of the article. EM involved in the data analysis and reviewed the article. All authors approved of the final version to be published. Conflict of interest All authors have declared that they have no conflict of interest. Acknowledgements This study was a part of the thesis of the first author to fulfill the requirement of the Doctoral degree in Epidemiology at Prince of Songkla University. Fellowship grant is supported by the World Health Organization (WHO), the Special Program on Human Reproduction (HRP), and the Discipline of Excellence in Epidemiology (Phase 2): Asia Mentoring Institute. We express our grateful thanks to the women who sacrificed their time to participate in this study. We acknowledge the support of Township Medical Officers and the Director of the Maternal and Reproductive Health Section, Department of Public Health. 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Journal of Public HealthOxford University Press

Published: Jan 27, 2018

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