Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis

حالات الإجحاف في رعاية ما بعد الولادة في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل: استعراض منهجي وتحليل وصفي

中低收入国家产后护理的不平等:系统回顾与综合分析

Inégalités des soins postnatals dans les pays à revenu faible et à revenu intermédiaire: revue systématique et méta-analyse

Неравенство с точки зрения ухода в постнатальном периоде в странах с низким и средним уровнем доходов: систематический обзор и метаанализ

Las desigualdades en la atención posnatal en los países de ingresos bajos y medianos: una revisión sistemática y metaanálisis

Étienne V Langlois Malgorzata Miszkurka Maria Victoria Zunzunegui Abdul Ghaffar Daniela Ziegler Igor Karp About the authors

Objective

To assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.

Methods

We searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.

Findings

A total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98) and 2.27 (95% CI: 1.75–2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01–1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.

Conclusion

In low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.


ملخص

الغرض

تقييم حالات الإجحاف الاجتماعية والاقتصادية والجغرافية والديمغرافية في الاستفادة من خدمات الرعاية الصحية بعد الولادة في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل.

الطريقة

أجرينا بحثاً في قواعد بيانات Medline وEmbase وكوكرين المركزية والمؤلفات غير الرسمية عن الدراسات التجريبية وشبه التجريبية والدراسات القائمة على الملاحظة التي تم إجراؤها في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل. وقمنا بتلخيص الدراسات ذات الصلة من حيث النوع وأجرينا تحليلات وصفية للاستفادة من خدمات رعاية ما بعد الولادة وفقاً للمؤشرات المحددة للوضع الاجتماعي والاقتصادي والإقامة في بيئة حضرية أو ريفية.

النتائج

تم إدراج ما مجموعه 36 دراسة في الملخص السردي وتم استخدام 10 منها لإجراء التحليلات الوصفية. ومقارنة بالنساء في الفئة الخميسية الأدنى للوضع الاجتماعي والاقتصادي، كانت نسب الاحتمال المجمعة لاستفادة النساء في الفئات الخميسية الثانية والثالثة والرابعة والخامسة من رعاية ما بعد الولادة على النحو التالي: 1.14 (فاصل الثقة 95 %، فاصل الثقة: من 0.96 إلى 1.34) و1.32 (فاصل الثقة: 95 %، فاصل الثقة: من 1.12 إلى 1.55) و1.60 (فاصل الثقة: 95 %، فاصل الثقة: من 1.30 إلى 1.98) و2.27 (فاصل الثقة: 95 %، فاصل الثقة: من 1.75 إلى 2.93)، على التوالي. ومقارنة بالنساء اللاتي يعشن في المناطق الريفية، كانت نسبة الاحتمال المجمعة لاستفادة النساء اللاتي يعشن في المناطق الحضرية من رعاية ما بعد الولادة 1.36 (فاصل الثقة: 95 %، فاصل الثقة: من 1.01 إلى 1.81). وأشار تقييم نوعي للبيانات المنشورة ذات الصلة كذلك إلى ازدياد الاستفادة من خدمات رعاية ما بعد الولادة بازدياد مستوى التثقيف.

الاستنتاج

مازال هناك إجحاف كبير في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل في الاستفادة من خدمات رعاية ما بعد الولادة، ويتباين ذلك بتباين الوضع الاجتماعي والاقتصادي وبين سكان المناطق الحضرية والريفية.

摘要

目的

评估中低收入国家在使用产后卫生保健服务的社会经济学、地理学与人口学方面的不平等现象。

方法

我们搜索了Medline、Embase、Cochrane Central数据库及灰色文献,查找在中低收入国家执行的试验、类试验和观察性研究。我们定性地总结了相关研究,并根据社会经济地位以及城市或农村居住等选定指标进行产后护理服务使用的综合分析。

结果

总共36项研究被列入叙述合成,其中10项被用作荟萃分析。与社会经济地位五等分位数最低等的女性相比,排在第二、三、四、五等分位数的女性使用产后护理的合并优势比分别是:1.14(95%置信区间,CI:0.96-1.34)、1.32(95% CI:1.12-1.55)、1.60(95% CI:1.30-1.98)和2.27(95% CI:1.75-2.93)。与居住在农村环境的女性相比,居住在城市的女性使用产后护理的合并优势比是1.36(95% CI:1.01-1.81)。对相关公布数据的定性评估同样表明,产后护理服务使用的增加与教育程度成正比。

结论

在中低收入国家,产后护理服务的使用依然处于极度不平等的阶段,因社会经济地位与城乡居民间的差异,产后护理的使用也明显不同。

Résumé

Objectif

Évaluer les inégalités socio-économiques, géographiques et démographiques en matière d'utilisation des soins de santé postnatals dans les pays à revenu faible et à revenu intermédiaire.

Méthodes

Nous avons effectué une recherche bibliographique dans les bases de données Medline, Embase et Cochrane Central, ainsi que dans la littérature grise, pour trouver les études expérimentales, quasi-expérimentales et observationnelles qui ont été menées dans les pays à revenu faible et à revenu intermédiaire. Nous avons fait la synthèse qualitative des études pertinentes et effectué des méta-analyses de l'utilisation des services de soins postnatals en fonction des indicateurs choisis pour le statut socio-économique et la résidence dans les zones urbaines ou rurales.

Résultats

Un total de 36 études ont été incluses dans la synthèse narrative et 10 d'entre elles ont été utilisées pour les méta-analyses. Par rapport aux femmes du quintile de statut socio-économique le plus bas, les rapports des cotes regroupés pour l'utilisation des soins postnatals par les femmes dans le deuxième, troisième quatrième et cinquième quintiles étaient de: 1,14 (intervalle de confiance à 95%, IC: 0,96-1,34) et 1,32 (IC à 95%: 1,12-1,55) et 1,60 (IC à 95%: 1,30-1,98) et 2,27 (IC à 95%: 1,75-2,93), respectivement. Par rapport aux femmes vivant en zones rurales, le rapport des cotes regroupé pour l'utilisation des soins postnatals par les femmes vivant en zones urbaines était de 1,36 (IC à 95%: 1,01-1,81). Une évaluation qualitative des données publiées pertinentes a également indiqué que l'utilisation des services de soins postnatals augmentait avec l’augmentation du niveau d'éducation.

Conclusion

Dans les pays à revenu faible et à revenu intermédiaire, l'utilisation de services de soins postnatals reste très inéquitable et varie manifestement avec le statut socio-économique et entre les résidents urbains et ruraux.

Резюме

Цель

Оценить социально-экономическое, географическое и демографическое неравенство в получении услуг по уходу в постнатальном периоде в странах с низким и средним уровнем доходов.

Методы

Мы изучили базы данных Medline, Embase и Cochrane Central, а также не индексированную в медицинских базах данных литературу, посвященную экспериментальным, квазиэкспериментальным и обсервационным исследованиям, которые проводились в странах с низким и средним уровнем доходов. Мы обобщили качественные результаты соответствующих исследований и выполнили метаанализ использования услуг по уходу в постнатальном периоде в соответствии с отобранными показателями социально-экономического статуса и проживания в городской или сельской местности.

Результаты

В нарративный синтез было включено в общей сложности 36 исследований; 10 из них использовались для метаанализа. Сравнив показатели женщин, входящих в нижний квинтиль социально-экономического статуса, мы получили следующие обобщенные отношения шансов на получение услуг по уходу в постнатальном периоде для женщин, входящих во второй, третий, четвертый и пятый квинтили: 1,14 (доверительный интервал (ДИ) 95%: 0,96–1,34), 1,32 (ДИ 95%: 1,12–1,55), 1,60 (ДИ 95%: 1,30–1,98) и 2,27 (ДИ 95%: 1,75–2,93) соответственно. По сравнению с женщинами, проживающими в сельской местности, обобщенные отношения шансов на получение услуг по уходу в постнатальном периоде для женщин, проживающих в городской местности, составили 1,36 (ДИ 95%: 1,01–1,81). Результаты качественной оценки соответствующих опубликованных данных также свидетельствуют о том, частота использования услуг по уходу в постнатальном периоде уменьшается с понижением уровня образования.

Вывод

В странах с низким и средним уровнем доходов сохраняется существенное неравенство в получении услуг по уходу в постнатальном периоде, которое зависит главным образом от социально-экономического статуса и отличается среди городских и сельских жителей.

Resumen

Objetivo

Evaluar las desigualdades socioeconómicas, geográficas y demográficas en el uso de los servicios de salud de atención posnatal en países de ingresos bajos y medianos.

Métodos

Se buscaron estudios experimentales, cuasiexperimentales y observacionales que se habían llevado a cabo en países de ingresos bajos y medianos en las bases de datos Medline, Embase y Cochrane Central, así como en la literatura gris. Se resumieron los estudios relevantes cualitativamente y se realizaron metaanálisis sobre el uso de los servicios de atención posnatal según indicadores seleccionados del nivel socioeconómico y residencia en un entorno urbano o rural.

Resultados

Se incluyó un total de 36 estudios en la síntesis narrativa, 10 de los cuales se utilizaron para los metaanálisis. En comparación con las mujeres del quintil más bajo del nivel socioeconómico, las razones de posibilidades agrupadas del uso de atención posnatal de las mujeres en el segundo, tercer, cuarto y quinto quintiles fueron: 1,14 (intervalo de confianza del 95 %, IC: 0,96–1,34), 1,32 (IC del 95 %: 1,12–1,55), 1,60 (IC del 95 %: 1,30–1,98) y 2,27 (IC del 95 %: 1,75–2,93), respectivamente. En comparación con las mujeres que viven en entornos rurales, la razón de posibilidades agrupada del uso de atención posnatal por mujeres que viven en entornos urbanos fue 1,36 (IC del 95 %: 1,01–1,81). Una evaluación cualitativa de los datos relevantes publicados indicó además que el uso de servicios de atención posnatal ha aumentado mediante el aumento del nivel de educación.

Conclusión

En los países de ingresos bajos y medianos, el uso de servicios de atención posnatal sigue siendo muy desigual y varía notablemente con el nivel socioeconómico y entre los residentes urbanos y rurales.

Introduction

Each year an estimated 289 000 women die worldwide from complications related to pregnancy, childbirth or the postnatal period1Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014. and up to two thirds of such maternal deaths occur after delivery.2Dhaher E, Mikolajczyk RT, Maxwell AE, Krämer A. Factors associated with lack of postnatal care among Palestinian women: a cross-sectional study of three clinics in the West Bank. BMC Pregnancy Childbirth. 2008;8(1):26. doi: http://dx.doi.org/10.1186/1471-2393-8-26 PMID: 18638395
https://doi.org/10.1186/1471-2393-8-26...
,3Ronsmans C, Graham WJ; Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet. 2006 Sep 30;368(9542):1189–200. doi: http://dx.doi.org/10.1016/S0140-6736(06)69380-X PMID: 17011946
https://doi.org/10.1016/S0140-6736(06)69...
Poor outcomes of maternal and neonatal care also include 2.9 million neonatal deaths per year.4Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al.; Lancet Every Newborn Study Group. Every Newborn: progress, priorities, and potential beyond survival. Lancet. 2014 Jul 12;384(9938):189–205. doi: http://dx.doi.org/10.1016/S0140-6736(14)60496-7 PMID: 24853593
https://doi.org/10.1016/S0140-6736(14)60...
Of the maternal and neonatal deaths that occur globally, 99% occur in low- and middle-income countries.1Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014.,5Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank Estimates. Geneva: World Health Organization; 2012.

According to the World Health Organization (WHO), the postnatal period begins immediately after childbirth and lasts six weeks.6WHO technical consultation on postpartum and postnatal care. Geneva: World Health Organization; 2010. In low-income countries, almost 40% of women experience complications after delivery and an estimated 15% develop potentially life-threatening problems.7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103 Postnatal care services are a fundamental element of the continuum of essential obstetric care – which also includes antenatal care and skilled birth attendance – that decreases maternal and neonatal morbidity and mortality in low- and middle-income countries.8Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34. doi: http://dx.doi.org/10.1186/1471-2393-9-34 PMID: 19671156
https://doi.org/10.1186/1471-2393-9-34...
,9Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007 Oct;85(10):812–9. doi: http://dx.doi.org/10.2471/BLT.06.035659 PMID: 18038064
https://doi.org/10.2471/BLT.06.035659...
Compared with other maternal and infant health services,1010 Fort AL. Coverage of post-partum and post-natal care in Egypt in 2005–2008 and Bangladesh in 2004–2007: levels, trends and unmet need. Reprod Health Matters. 2012 Jun;20(39):81–92. doi: http://dx.doi.org/10.1016/S0968-8080(12)39600-6 PMID: 22789085
https://doi.org/10.1016/S0968-8080(12)39...
coverage for postnatal care tends to be relatively poor. Increasing such coverage has been highlighted as a priority.1111 Matijasevich A, Santos IS, Silveira MF, Domingues MR, Barros AJ, Marco PL, et al. Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health. 2009;9(1):335. doi: http://dx.doi.org/10.1186/1471-2458-9-335 PMID: 19751521
https://doi.org/10.1186/1471-2458-9-335...
In the Democratic Republic of the Congo, for example, at least 93% of pregnant women receive antenatal care and skilled birth attendance but only 35% of birthing women receive postnatal care.1212 Abel Ntambue ML, Françoise Malonga K, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo–a case study of Lubumbashi City. BMC Pregnancy Childbirth. 2012;12(66):66. PMID: 22780957 In Kenya, fewer than 20% of women use postnatal care services.1313 Postpartum empowerment: an integrated approach driving demand and delivery of high quality, low-cost postnatal services in Kenya. Nairobi: Jacaranda Health Organization; 2012. Available from: http://savinglivesatbirth.net/summaries/162 [cited 2013 May 23].
http://savinglivesatbirth.net/summaries/...
In 2014, WHO recommended that a mother and her newborn child should receive postnatal care within 24 hours of the birth and then at least three more times – i.e. at least on day three after the birth, in the second week after the birth and six weeks after the birth.1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014. Postnatal care services can be defined as preventive care practices and assessments that are designed to identify and manage or refer complications for both the mother and the neonate. Typically, such services include an integrated package of routine maternal and neonatal care as well as extra care for neonates that are considered particularly vulnerable because, for example, they are preterm, have a low birth weight, are small for gestational age or have mothers infected with human immunodeficiency virus (HIV).1515 Opportunities for Africa’s newborns. Geneva: World Health Organization; 2006. Possible postnatal interventions for the mother include: (i) iron and folic acid supplementation for at least three months; (ii) screening for – and treatment of – infection, haemorrhage, thromboembolism, postnatal depression and other conditions; (iii) prophylactic antibiotics given to women who have a third- or fourth-degree perineal tear; and (iv) counselling on early and exclusive breastfeeding, nutrition, birth spacing and family planning options – including any available contraception.1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014.,1616 Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol. 2010 Apr;39 Suppl 1:i144–54. doi: http://dx.doi.org/10.1093/ije/dyq031 PMID: 20348117
https://doi.org/10.1093/ije/dyq031...
,1717 Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
https://doi.org/10.1111/j.1471-0528.2004...
Possible interventions for the neonate include: (i) care of the umbilical cord (ii) special care for preterm, low-birth-weight and HIV-infected neonates;1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014.,1515 Opportunities for Africa’s newborns. Geneva: World Health Organization; 2006.,1818 USAID/BASICS (Basic Support for Institutionalizing Child Survival) and the Prevention of Postpartum Hemorrhage Initiative. Integrated maternal and newborn care: supervisory and evaluation checklists. Arlington: United States Agency for International Development; 2009. Available from: http://www.basics.org/documents/Supervisory-and-Evaluation-Checklists_Newborn-Toolkit_BASICS.pdf [cited 2015 Jan 26].
http://www.basics.org/documents/Supervis...
(iii) screening and treatment of infections and postnatal growth restriction; (iv) assessment of factors predisposing to infant anaemia;1919 Crawley J. Reducing the burden of anemia in infants and young children in malaria-endemic countries of Africa: from evidence to action. Am J Trop Med Hyg. 2004 Aug;71(2) Suppl:25–34. PMID: 15331816 and (v) teaching the mother to seek additional care for her neonate if she notices danger signs such as convulsions or problems with feeding.1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014.

Low use of postnatal care services is associated with lack of education, poverty and limited access to health-care facilities.2Dhaher E, Mikolajczyk RT, Maxwell AE, Krämer A. Factors associated with lack of postnatal care among Palestinian women: a cross-sectional study of three clinics in the West Bank. BMC Pregnancy Childbirth. 2008;8(1):26. doi: http://dx.doi.org/10.1186/1471-2393-8-26 PMID: 18638395
https://doi.org/10.1186/1471-2393-8-26...
However, these associations have not been assessed systematically. We therefore conducted a systematic review of the relevant evidence from low- and middle-income countries, to inform policy-making, help strengthen health systems and increase access to – and use of – postnatal care services.

Methods

We followed guidelines for systematic reviews from the Cochrane Collaboration2020 Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). Oxford: The Cochrane Collaboration; 2011. Available from: http://www.cochrane.handbook.org [cited 2015 Jan 6].
http://www.cochrane.handbook.org...
and a standardized methodology described in an explicit protocol.2121 Langlois EV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low- and middle-income countries. Syst Rev. 2013;2(1):55. doi: http://dx.doi.org/10.1186/2046-4053-2-55 PMID: 23830501
https://doi.org/10.1186/2046-4053-2-55...
The review was registered with the Prospero database (registration number: CRD42013004661) and results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.2222 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339 jul21 1:b2535. doi: http://dx.doi.org/10.1136/bmj.b2535 PMID: 19622551
https://doi.org/10.1136/bmj.b2535...

Literature search

To identify the studies of interest, we searched the Medline, Embase and Cochrane Central databases and grey literature for relevant medical subject headings and keywords. We focused on articles published between 1 January 1960 and 31 May 2013 in English, French, Spanish, Portuguese and Chinese and were assisted by an expert librarian. Our search strategy combined terms related to postnatal or postpartum care, use or accessibility, determinants or inequities and low- or middle-income countries. Our full search strategy is detailed in Appendix A (available at: https://dl.dropboxusercontent.com/u/28446882/Appendix%20A.pdf). To identify further data that might be useful, we also checked the reference lists of the articles found to be of potential interest, visited institutional web sites and contacted the authors of some of the articles of interest and other experts in the field.

Inclusion criteria

We retrieved data from experimental, quasi-experimental and observational studies of women aged 15–49 years, that had been implemented in low- or middle-income countries as defined by the World Bank.2323 Country and lending groups [Internet]. Washington: World Bank; 2014. Available from: http://data.worldbank.org/about/country-and-lending-groups [cited 2014 Jan 25].
http://data.worldbank.org/about/country-...
The primary outcome of interest was the use of postnatal care services – i.e. at least one follow-up visit in the 42 days post-childbirth. We included studies in which the potential socioeconomic, geographical and/or demographic determinants of the use of postnatal care had been assessed. The potential socioeconomic determinants that we investigated were socioeconomic status, occupation and education. We investigated distance and travel time to a health centre and place of residence – i.e. urban or rural – as potential geographical determinants and ethnicity, marital status, religion and immigration status as potential demographic determinants. We analysed data from studies that included at least one association measure – such as a frequency ratio or difference – or the result of at least one statistical test in which use of postnatal care had been compared across two or more categories. We included relative comparisons to a reference group (e.g. concentration indexes) and absolute comparisons (e.g. slope indexes of inequality). In some relevant studies, a concentration index was used to measure the relationship between accumulated proportions of mothers ranked by their socioeconomic status against the cumulative proportion of postnatal care use. In these studies, a positive value for the index indicates that rich households have greater coverage than poor households, a negative index indicates that poor households have greater coverage than rich households and zero values for the index that coverage is independent of socioeconomic status. Other studies used a slope index of inequality to estimate the absolute difference in percentage postnatal care coverage between individuals at the top and bottom of the socioeconomic status scale. In such studies, a high slope index of inequality would have indicated great inequity in coverage.

Data extraction

The eligibility of each study identified in the initial screening was assessed by two reviewers using a standardized form with explicit inclusion and exclusion criteria. There was a high level of agreement between the reviewers (Cohen’s kappa,2424 Rothman KJ, Greenland S, Lash TL. Modern epidemiology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. κ: 0.92). Data were extracted with a standardized data collection form2121 Langlois EV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low- and middle-income countries. Syst Rev. 2013;2(1):55. doi: http://dx.doi.org/10.1186/2046-4053-2-55 PMID: 23830501
https://doi.org/10.1186/2046-4053-2-55...
that had been pilot tested on a random sample of studies. We collected data on country, setting, year of publication, study design, sample size, population attributes, outcome definition, comparison groups, point estimates and precision measures.

Quality assessment

Two individuals, working independently, assessed the scientific quality of each selected study using the Effective Public Health Practice Project’s quality assessment tool for quantitative studies – after extending the criteria for selection bias assessment.2525 Quality assessment tool for quantitative studies. Hamilton: Effective Public Health Practice Project; 2013. Available from: http://www.ephpp.ca/tools.html [cited 2013 Mar 19].
http://www.ephpp.ca/tools.html...
Scientific quality was categorized as high, moderate or low if, respectively, the risk of bias in the study results was considered to be very low, low or high. The level of agreement between the two assessors of quality was good (κ: 0.75). Discrepancies in the assessment of eligibility or scientific quality were resolved in discussions with an experienced researcher.

Data synthesis

Evidence tables were generated to summarize the selected studies and results descriptively. We conducted a qualitative synthesis of the findings. We also conducted a meta-analysis of selected studies that provided a comparable classification of the outcome and determinants of interest. For this purpose, we also required either estimates of the standard errors for the association measure or confidence intervals that allowed us to derive such estimates.2121 Langlois EV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low- and middle-income countries. Syst Rev. 2013;2(1):55. doi: http://dx.doi.org/10.1186/2046-4053-2-55 PMID: 23830501
https://doi.org/10.1186/2046-4053-2-55...
Many of the studies included in the systematic review had to be excluded from the meta-analysis because of differences in the classification or definition of determinants. We pooled the association measures for socioeconomic status and geography, as represented by socioeconomic status quintile and an indicator of urban/rural place of residence, respectively. We assessed heterogeneity of these results using Cochran’s Q test2626 Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic reviews. Ann Intern Med. 1997 Nov 1;127(9):820–6. doi: http://dx.doi.org/10.7326/0003-4819-127-9-199711010-00008 PMID: 9382404
https://doi.org/10.7326/0003-4819-127-9-...
and the I2 statistic. We used random-effects meta-analysis models when heterogeneity was statistically significant (P > 0.1) and I2 was moderate or high according to the criteria of Higgins et al.2727 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. doi: http://dx.doi.org/10.1136/bmj.327.7414.557 PMID: 12958120
https://doi.org/10.1136/bmj.327.7414.557...
We conducted sensitivity analyses by removing studies deemed to be of low quality or potential outliers.2828 Viechtbauer W, Cheung MW-L. Outlier and influence diagnostics for meta-analysis. Res Synth Methods. 2010;1(2):112–25. doi: http://dx.doi.org/10.1002/jrsm.11
https://doi.org/10.1002/jrsm.11...
,2929 Gumedze FN, Jackson D. A random effects variance shift model for detecting and accommodating outliers in meta-analysis. BMC Med Res Methodol. 2011;11(1):19. doi: http://dx.doi.org/10.1186/1471-2288-11-19 PMID: 21324180
https://doi.org/10.1186/1471-2288-11-19...
We assessed publication bias in the meta-analyses with funnel plots. Data analysis was performed using Stata version 12.0 (StataCorp LP, College Station, United States of America).

Results

Our initial search produced 3152 articles of potential interest and articles describing 36 studies2Dhaher E, Mikolajczyk RT, Maxwell AE, Krämer A. Factors associated with lack of postnatal care among Palestinian women: a cross-sectional study of three clinics in the West Bank. BMC Pregnancy Childbirth. 2008;8(1):26. doi: http://dx.doi.org/10.1186/1471-2393-8-26 PMID: 18638395
https://doi.org/10.1186/1471-2393-8-26...
,7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,1111 Matijasevich A, Santos IS, Silveira MF, Domingues MR, Barros AJ, Marco PL, et al. Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health. 2009;9(1):335. doi: http://dx.doi.org/10.1186/1471-2458-9-335 PMID: 19751521
https://doi.org/10.1186/1471-2458-9-335...
,1212 Abel Ntambue ML, Françoise Malonga K, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo–a case study of Lubumbashi City. BMC Pregnancy Childbirth. 2012;12(66):66. PMID: 22780957,1717 Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
https://doi.org/10.1111/j.1471-0528.2004...
,3030 Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
https://doi.org/10.1186/1742-4755-8-10...
6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
contributed to our qualitative synthesis of evidence (Fig. 1). Data from 10 of the studies were included in the meta-analysis.7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,3030 Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
https://doi.org/10.1186/1742-4755-8-10...
3232 Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: a cross-sectional analysis. Int J Equity Health. 2010;9(9):9. doi: http://dx.doi.org/10.1186/1475-9276-9-9 PMID: 20361875
https://doi.org/10.1186/1475-9276-9-9...
,3434 Anwar I, Sami M, Akhtar N, Chowdhury ME, Salma U, Rahman M, et al. Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh. Bull World Health Organ. 2008 Apr;86(4):252–9. doi: http://dx.doi.org/10.2471/BLT.07.042754 PMID: 18438513
https://doi.org/10.2471/BLT.07.042754...
,3535 Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
https://doi.org/10.1186/1471-2393-9-43...
,3939 Halder AK, Saha UR, Kabir M. Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004. World Health Popul. 2007 Apr;9(2):48–63. doi: http://dx.doi.org/10.12927/whp.2007.18853 PMID: 18270506
https://doi.org/10.12927/whp.2007.18853...
,4141 Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
https://doi.org/10.1186/1475-9276-10-59...
,5151 Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One. 2012;7(2):e31666. doi: http://dx.doi.org/10.1371/journal.pone.0031666 PMID: 22355386
https://doi.org/10.1371/journal.pone.003...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
The 36 studies included in our qualitative synthesis of evidence comprised two randomized controlled trials, three quasi-experimental studies, two cohort and 28 cross-sectional studies, and one investigation of 31 demographic and health surveys. Of these 36 studies, 11 were conducted in low-income countries, 24 in middle-income countries and one in both low- and middle-income countries. Three, 26 and six of the 36 studies were deemed to be of high, moderate and low scientific quality, respectively. A lack of information on methodology prevented the assessment of the scientific quality of one study included in the qualitative synthesis (Table 1, available at: http://www.who.int/bulletin/volumes/93/4/14-140996).

Fig. 1
Flowchart for the selection of studies on potential determinants of the use of postnatal care in low- and middle-income countries
Table 1
Characteristics of studies included in the systematic review on the use of postnatal care services in low- and middle-income countries

Socioeconomic determinants

Socioeconomic status

Our qualitative assessment of relevant studies indicates that there was a gradient in the use of postnatal care according to socioeconomic status – as measured on different scales (Table 2, available at: http://www.who.int/bulletin/volumes/93/4/14-140996).2Dhaher E, Mikolajczyk RT, Maxwell AE, Krämer A. Factors associated with lack of postnatal care among Palestinian women: a cross-sectional study of three clinics in the West Bank. BMC Pregnancy Childbirth. 2008;8(1):26. doi: http://dx.doi.org/10.1186/1471-2393-8-26 PMID: 18638395
https://doi.org/10.1186/1471-2393-8-26...
,7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,1111 Matijasevich A, Santos IS, Silveira MF, Domingues MR, Barros AJ, Marco PL, et al. Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health. 2009;9(1):335. doi: http://dx.doi.org/10.1186/1471-2458-9-335 PMID: 19751521
https://doi.org/10.1186/1471-2458-9-335...
,1212 Abel Ntambue ML, Françoise Malonga K, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo–a case study of Lubumbashi City. BMC Pregnancy Childbirth. 2012;12(66):66. PMID: 22780957,1717 Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
https://doi.org/10.1111/j.1471-0528.2004...
,3030 Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
https://doi.org/10.1186/1742-4755-8-10...
5454 Zere E, Tumusiime P, Walker O, Kirigia J, Mwikisa C, Mbeeli T. Inequities in utilization of maternal health interventions in Namibia: implications for progress towards MDG 5 targets. Int J Equity Health. 2010;9(1):16. doi: http://dx.doi.org/10.1186/1475-9276-9-16 PMID: 20540793
https://doi.org/10.1186/1475-9276-9-16...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
Results of our meta-analysis that included data on socioeconomic status from studies of moderate quality also indicated that the higher the socioeconomic status of the mother, the more likely she was to access postnatal care (Fig. 2, Fig. 3, Fig. 4 and Fig. 5).

Table 2
Socioeconomical determinants for the use of postnatal care services in low- and middle-income countries
Fig. 2
Odds ratio for the association between socioeconomic status and use of postnatal care services; quintile 5 versus quintile 1 (reference)
Fig. 3
Odds ratio for the association between socioeconomic status and use of postnatal care services; quintile 4 versus quintile 1 (reference)
Fig. 4
Odds ratio for the association between socioeconomic status and use of postnatal care services; quintile 3 versus quintile 1 (reference)
Fig. 5
Odds ratio for the association between socioeconomic status and use of postnatal care services; quintile 2 versus quintile 1 (reference)

Meta-analysis was used to derive pooled adjusted odds ratios (OR) from 10 studies and a total of 136 431 women. For each quintile of socioeconomic status, the Q test gave a significant result and the I2 statistic fell between 50% and 75% – indicating moderate heterogeneity.2727 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. doi: http://dx.doi.org/10.1136/bmj.327.7414.557 PMID: 12958120
https://doi.org/10.1136/bmj.327.7414.557...
When the lowest quintile (Q1) was used as the reference, the pooled OR for the highest quintile (Q5) was 2.27 (95% confidence interval, CI: 1.75–2.93). The corresponding OR for Q4, Q3 and Q2 were lower, at 1.60 (95% CI: 1.30–1.98; I2: 70%), 1.32 (95% CI: 1.12–1.55; I2: 50%) and 1.14 (95% CI: 0.96–1.34; I2: 52%), respectively.

In a sensitivity analysis, we removed the potentially atypical data reported by Amin et al.3232 Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: a cross-sectional analysis. Int J Equity Health. 2010;9(9):9. doi: http://dx.doi.org/10.1186/1475-9276-9-9 PMID: 20361875
https://doi.org/10.1186/1475-9276-9-9...
The pooled OR for Q5, Q4, Q3 and Q2 – with Q1 used as the reference – were reduced to 2.09 (95% CI: 1.70–2.56), 1.55 (95% CI: 1.27–1.90), 1.30 (95% CI: 1.10–1.54) and 1.08 (95% CI: 0.95–1.24), respectively.

The data in a report5555 Countdown to 2015. Maternal, newborn & child survival. Building a future for women and children. The 2012 report. Geneva: World Health Organization; 2012. Available from: http://www.countdown2015mnch.org/documents/2012Report/2012-complete-no-profiles.pdf [cited 2015 Jan 26].
http://www.countdown2015mnch.org/documen...
included in the systematic review showed concentration indexes and slope indexes of inequality for use of postnatal care in 31 countries (Table 3). For the low-income countries, the mean concentration index was 0.23 and the mean slope index of inequality was 53%. The corresponding values for the middle-income countries were 0.18 and 61%, respectively. In Pakistan, exposure to a voucher scheme led to significant increase in the use of postnatal care (OR: 4.98; P < 0.001).3030 Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
https://doi.org/10.1186/1742-4755-8-10...

Table 3
Socioeconomic inequities in postnatal care coverage

Level of education

Our qualitative assessment of studies indicated marked variations in the use of postnatal care according to the level of education of the women investigated – or their partners (Table 2). Compared to women who had received no formal education, women who had attended primary education were more likely to use postnatal care3030 Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
https://doi.org/10.1186/1742-4755-8-10...
,3535 Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
https://doi.org/10.1186/1471-2393-9-43...
,4848 Sarma S, Rempel H. Household decisions to utilize maternal healthcare in rural and urban India. World Health Popul. 2007 Jan;9(1):24–45. doi: http://dx.doi.org/10.12927/whp.2007.18712 PMID: 18270498
https://doi.org/10.12927/whp.2007.18712...
,5050 Singh A, Padmadas SS, Mishra US, Pallikadavath S, Johnson FA, Matthews Z. Socio-economic inequalities in the use of postnatal care in India. PLoS One. 2012;7(5):e37037. doi: http://dx.doi.org/10.1371/journal.pone.0037037 PMID: 22623976
https://doi.org/10.1371/journal.pone.003...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
and women who had completed secondary school were the most likely to access postnatal care.7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,1717 Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
https://doi.org/10.1111/j.1471-0528.2004...
,3838 Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. doi: http://dx.doi.org/10.1186/1471-2393-7-19 PMID: 17767710
https://doi.org/10.1186/1471-2393-7-19...
,3939 Halder AK, Saha UR, Kabir M. Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004. World Health Popul. 2007 Apr;9(2):48–63. doi: http://dx.doi.org/10.12927/whp.2007.18853 PMID: 18270506
https://doi.org/10.12927/whp.2007.18853...
,4141 Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
https://doi.org/10.1186/1475-9276-10-59...
,4848 Sarma S, Rempel H. Household decisions to utilize maternal healthcare in rural and urban India. World Health Popul. 2007 Jan;9(1):24–45. doi: http://dx.doi.org/10.12927/whp.2007.18712 PMID: 18270498
https://doi.org/10.12927/whp.2007.18712...
,4949 Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007 Sep;39(5):671–92. doi: http://dx.doi.org/10.1017/S0021932007001952 PMID: 17359562
https://doi.org/10.1017/S002193200700195...
,5151 Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One. 2012;7(2):e31666. doi: http://dx.doi.org/10.1371/journal.pone.0031666 PMID: 22355386
https://doi.org/10.1371/journal.pone.003...
In three studies, the duration of maternal schooling was found to be positively correlated with postnatal care use.3333 Anson O. Utilization of maternal care in rural HeBei province, the People’s Republic of China: individual and structural characteristics. Health Policy. 2004 Nov;70(2):197–206. doi: http://dx.doi.org/10.1016/j.healthpol.2004.03.001 PMID: 15364149
https://doi.org/10.1016/j.healthpol.2004...
,4444 Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009 Sep;69(6):926–33. doi: http://dx.doi.org/10.1016/j.socscimed.2009.07.008 PMID: 19656604
https://doi.org/10.1016/j.socscimed.2009...
,4646 Okafor CB. Availability and use of services for maternal and child health care in rural Nigeria. Int J Gynaecol Obstet. 1991 Apr;34(4):331–46. doi: http://dx.doi.org/10.1016/0020-7292(91)90602-2 PMID: 1674481
https://doi.org/10.1016/0020-7292(91)906...
Compared with other women, those with husbands who had completed secondary school also appeared more likely to use postnatal care.3838 Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. doi: http://dx.doi.org/10.1186/1471-2393-7-19 PMID: 17767710
https://doi.org/10.1186/1471-2393-7-19...
,4141 Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
https://doi.org/10.1186/1475-9276-10-59...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
In Lebanon, an educational intervention to emphasize the importance of postnatal care led to a marked increase in the use of such care (relative risk: 2.8; 95% CI: 2.2–3.4).1717 Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
https://doi.org/10.1111/j.1471-0528.2004...
Inconsistent classification of education status prevented us from performing a meta-analysis of these apparent determinants of the use of postnatal care.

Occupation

The income-earning occupations of women and their husbands appear to influence the women’s use of postnatal care (Table 2). For example, women married to men with professional, technical or managerial occupations were more likely to use postnatal care than women married to manual labourers (OR: 2.22; 95% CI: 1.62–2.81).7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103 Similarly, women married to men with well paid jobs were more likely to use postnatal care than women married to farmers (OR: 1.45; P < 0.05).3939 Halder AK, Saha UR, Kabir M. Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004. World Health Popul. 2007 Apr;9(2):48–63. doi: http://dx.doi.org/10.12927/whp.2007.18853 PMID: 18270506
https://doi.org/10.12927/whp.2007.18853...
In China, women with so-called white-collar occupations were more likely to use postnatal care than other women (OR: 2.17; P < 0.001).3333 Anson O. Utilization of maternal care in rural HeBei province, the People’s Republic of China: individual and structural characteristics. Health Policy. 2004 Nov;70(2):197–206. doi: http://dx.doi.org/10.1016/j.healthpol.2004.03.001 PMID: 15364149
https://doi.org/10.1016/j.healthpol.2004...
Inconsistent classification of occupation impeded any corresponding meta-analysis.

Geographical determinants

A qualitative assessment of the evidence indicated that postnatal care was more commonly used by women living in urban areas than by their rural counterparts (Table 4).7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,3535 Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
https://doi.org/10.1186/1471-2393-9-43...
,3939 Halder AK, Saha UR, Kabir M. Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004. World Health Popul. 2007 Apr;9(2):48–63. doi: http://dx.doi.org/10.12927/whp.2007.18853 PMID: 18270506
https://doi.org/10.12927/whp.2007.18853...
,4141 Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
https://doi.org/10.1186/1475-9276-10-59...
,4949 Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007 Sep;39(5):671–92. doi: http://dx.doi.org/10.1017/S0021932007001952 PMID: 17359562
https://doi.org/10.1017/S002193200700195...
,5252 Stupp PW, Macke BA, Monteith R, Paredez S. Ethnicity and the use of health services in Belize. J Biosoc Sci. 1994 Apr;26(2):165–77. doi: http://dx.doi.org/10.1017/S0021932000021209 PMID: 8014173
https://doi.org/10.1017/S002193200002120...
,5656 Chatterjee A, Paily VP. Achieving millennium development goals 4 and 5 in India. BJOG. 2011 Sep;118 Suppl 2:47–59. doi: http://dx.doi.org/10.1111/j.1471-0528.2011.03112.x PMID: 21951502
https://doi.org/10.1111/j.1471-0528.2011...
5858 Titaley CR, Dibley MJ, Roberts CL. Factors associated with non-utilisation of postnatal care services in Indonesia. J Epidemiol Community Health. 2009 Oct;63(10):827–31. doi: http://dx.doi.org/10.1136/jech.2008.081604 PMID: 19414443
https://doi.org/10.1136/jech.2008.081604...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
Our meta-analysis of this trend was based on five studies and a total of 46 913 women.7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103,3535 Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
https://doi.org/10.1186/1471-2393-9-43...
,4141 Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
https://doi.org/10.1186/1475-9276-10-59...
,5858 Titaley CR, Dibley MJ, Roberts CL. Factors associated with non-utilisation of postnatal care services in Indonesia. J Epidemiol Community Health. 2009 Oct;63(10):827–31. doi: http://dx.doi.org/10.1136/jech.2008.081604 PMID: 19414443
https://doi.org/10.1136/jech.2008.081604...
,6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
As a Q test gave a significant result (P < 0.001) and I2 was 83.7%, heterogeneity was considered high.2727 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. doi: http://dx.doi.org/10.1136/bmj.327.7414.557 PMID: 12958120
https://doi.org/10.1136/bmj.327.7414.557...
With women in rural areas used as the reference, our initial estimate of the pooled OR for use of postnatal care by women residing in urban areas was 1.36 (95% CI: 1.01–1.81; Fig. 6). After removing the study deemed to be of low quality,5858 Titaley CR, Dibley MJ, Roberts CL. Factors associated with non-utilisation of postnatal care services in Indonesia. J Epidemiol Community Health. 2009 Oct;63(10):827–31. doi: http://dx.doi.org/10.1136/jech.2008.081604 PMID: 19414443
https://doi.org/10.1136/jech.2008.081604...
the estimated pooled OR became 1.21 (95% CI: 0.95–1.53). In several studies included in our systematic review, distance to the nearest health facility was also found to be associated with use of postnatal care services. In India, for example, the relevant OR for distances of 2–5 and at least 6 km – with a distance of less than 2 km used as the reference – were 0.80 (95% CI: 0.67–0.95) and 0.64 (95% CI: 0.50–0.83), respectively.4444 Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009 Sep;69(6):926–33. doi: http://dx.doi.org/10.1016/j.socscimed.2009.07.008 PMID: 19656604
https://doi.org/10.1016/j.socscimed.2009...
In rural areas of India, the presence of a bus service has been found to increase the use of postnatal care services (OR: 1.18; P < 0.01).4848 Sarma S, Rempel H. Household decisions to utilize maternal healthcare in rural and urban India. World Health Popul. 2007 Jan;9(1):24–45. doi: http://dx.doi.org/10.12927/whp.2007.18712 PMID: 18270498
https://doi.org/10.12927/whp.2007.18712...

Table 4
Geographical determinants for the use of postnatal care services in low- and middle-income countries
Fig. 6
Odds ratio for the association between place of residence and use of postnatal care services

Demographic determinants

Religion

In one study, use of postnatal care services was higher among Muslim women than among Christian women (OR: 2.01; 95% CI: 1.24–3.25).6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
In contrast, in another study, Muslim women seemed less likely to use such services than their non-Muslim counterparts (OR: 0.77; 95% CI: 0.61–1.34).7Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103 In Nepal, compared with Hindu women, Buddhist women were less likely to use postnatal care services (OR: 0.25; P < 0.001).4949 Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007 Sep;39(5):671–92. doi: http://dx.doi.org/10.1017/S0021932007001952 PMID: 17359562
https://doi.org/10.1017/S002193200700195...
Overall, our systematic review of relevant studies revealed no clear trend in the use of such services according to religion (Table 5).

Table 5
Demographical determinants for the use of postnatal care services in low- and middle-income countries

Ethnicity

In India, women belonging to the lower social groups – i.e. those belonging to scheduled castes (OR: 0.69; 95% CI: 0.55–0.86), scheduled tribes (OR: 0.71; 95% CI: 0.54–0.91) or other so-called backward classes (OR: 0.58; 95% CI: 0.48–0.71) – were found to be less likely to use postnatal care services than those belonging to upper castes (Table 5).5151 Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One. 2012;7(2):e31666. doi: http://dx.doi.org/10.1371/journal.pone.0031666 PMID: 22355386
https://doi.org/10.1371/journal.pone.003...
Although we found statistically significant differences in the use of postnatal care services according to the ethnicity of the women investigated, our systematic review revealed no clear trend in the use of such services according to whether the woman involved belonged to a minority or majority group.1111 Matijasevich A, Santos IS, Silveira MF, Domingues MR, Barros AJ, Marco PL, et al. Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health. 2009;9(1):335. doi: http://dx.doi.org/10.1186/1471-2458-9-335 PMID: 19751521
https://doi.org/10.1186/1471-2458-9-335...
,3535 Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
https://doi.org/10.1186/1471-2393-9-43...
,3838 Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. doi: http://dx.doi.org/10.1186/1471-2393-7-19 PMID: 17767710
https://doi.org/10.1186/1471-2393-7-19...
,4444 Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009 Sep;69(6):926–33. doi: http://dx.doi.org/10.1016/j.socscimed.2009.07.008 PMID: 19656604
https://doi.org/10.1016/j.socscimed.2009...
,5151 Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One. 2012;7(2):e31666. doi: http://dx.doi.org/10.1371/journal.pone.0031666 PMID: 22355386
https://doi.org/10.1371/journal.pone.003...
,5252 Stupp PW, Macke BA, Monteith R, Paredez S. Ethnicity and the use of health services in Belize. J Biosoc Sci. 1994 Apr;26(2):165–77. doi: http://dx.doi.org/10.1017/S0021932000021209 PMID: 8014173
https://doi.org/10.1017/S002193200002120...
,5959 Mullany LC, Lee CI, Yone L, Paw P, Oo EK, Maung C, et al. Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma. PLoS Med. 2008 Dec 23;5(12):1689–98. doi: http://dx.doi.org/10.1371/journal.pmed.0050242 PMID: 19108601
https://doi.org/10.1371/journal.pmed.005...

Discussion

We have systematically reviewed studies assessing inequities in the use of postnatal care services in low- and middle-income countries. We found strong and consistent evidence indicating that the use of such services was relatively high among women with high socioeconomic status and among more educated women. In general, women with high socioeconomic status belong to those households that can afford the medical, non-medical and opportunity costs of postnatal care.8Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34. doi: http://dx.doi.org/10.1186/1471-2393-9-34 PMID: 19671156
https://doi.org/10.1186/1471-2393-9-34...
In addition, such women may be relatively empowered and have more autonomy than their poorer counterparts.6161 Navaneetham K, Dharmalingam A. Utilization of maternal health care services in Southern India. Soc Sci Med. 2002 Nov;55(10):1849–69. doi: http://dx.doi.org/10.1016/S0277-9536(01)00313-6 PMID: 12383469
https://doi.org/10.1016/S0277-9536(01)00...
Educated women are considered to have relatively good access to – and management of – health service information, and relatively accurate and detailed perceptions of diseases and their complications and treatments.8Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34. doi: http://dx.doi.org/10.1186/1471-2393-9-34 PMID: 19671156
https://doi.org/10.1186/1471-2393-9-34...
,6262 LeVine RA, LeVine SE, Rowe ML, Schnell-Anzola B. Maternal literacy and health behavior: a Nepalese case study. Soc Sci Med. 2004 Feb;58(4):863–77. doi: http://dx.doi.org/10.1016/S0277-9536(03)00261-2 PMID: 14672599
https://doi.org/10.1016/S0277-9536(03)00...
There also seems to be an independent association between a woman’s use of maternal services and her partner’s education.6363 Guliani H, Sepehri A, Serieux J. What impact does contact with the prenatal care system have on women’s use of facility delivery? Evidence from low-income countries. Soc Sci Med. 2012 Jun;74(12):1882–90. doi: http://dx.doi.org/10.1016/j.socscimed.2012.02.008 PMID: 22483706
https://doi.org/10.1016/j.socscimed.2012...

In addition to increasing household income, employment can increase awareness and modify a person’s behaviour, through social and community interactions.4949 Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007 Sep;39(5):671–92. doi: http://dx.doi.org/10.1017/S0021932007001952 PMID: 17359562
https://doi.org/10.1017/S002193200700195...
However, in low- and middle-income countries, there seems to be no clear and consistent association between a woman’s income-generating employment and her use of postnatal care services. A woman in gainful employment may still have no control over any of her household’s finances. In addition, a woman’s economic activity may also be poverty-induced, only seasonal and/or relatively poorly remunerated.8Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34. doi: http://dx.doi.org/10.1186/1471-2393-9-34 PMID: 19671156
https://doi.org/10.1186/1471-2393-9-34...
,6464 Addai I. Determinants of use of maternal-child health services in rural Ghana. J Biosoc Sci. 2000 Jan;32(1):1–15. PMID: 10676056

Compared with women living in rural areas, urban women have generally better access to postnatal care services as well as other advantages of urban life, such as greater exposure to health-promotion programmes.6060 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
https://doi.org/10.1016/j.whi.2012.05.00...
,6565 Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al.; Lancet Maternal Survival Series steering group. Going to scale with professional skilled care. Lancet. 2006 Oct 14;368(9544):1377–86. doi: http://dx.doi.org/10.1016/S0140-6736(06)69382-3 PMID: 17046470
https://doi.org/10.1016/S0140-6736(06)69...
In many rural areas, improvements in the numbers of primary health care facilities, the provision of postnatal care services of high quality and public transportation are required. Although the relationship between ethnicity and use of postnatal care services appears complex, there are some ethnicities, such as India’s lower castes, that often seem to be disadvantaged.6666 Meshram II, Kodavanti MR, Chitty GR, Manchala R, Kumar S, Kakani SK, et al. Influence of feeding practices and associated factors on the nutritional status of infants in rural areas of Madhya Pradesh state, India. Asia Pac J Public Health. 2013 May 10; [Epub ahead of print]. doi: http://dx.doi.org/10.1177/1010539513486174 PMID: 23666834
https://doi.org/10.1177/1010539513486174...

We found insufficient homogeneous classification of data to conduct meta-analyses for occupation or level of education. Our meta-analysis for place of residence may have been weakened by the suboptimal precision of a between-studies variance estimate.6767 Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. A basic introduction to fixed effect and random effects models for meta-analysis. Res Synth Methods. 2010;1(2):97–111. doi: http://dx.doi.org/10.1002/jrsm.12
https://doi.org/10.1002/jrsm.12...
Despite these limitations, our study indicates that the use of postnatal care remains highly inequitable according to socioeconomic status, education and geographical access to health facilities. There are several research and knowledge gaps that need to be filled. For example, we need research to further understand health-seeking behaviours and to inform policy-makers. As most maternal deaths occur during the postnatal period, primary research on postnatal care services should be prioritized. Further research on the contextual and systems-level determinants of the use of such services and the effectiveness of strategies to improve the coverage and quality of postnatal care is also needed. It remains unclear if the number and timing of postnatal consultations recommended by WHO are optimal and achievable in every setting.1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014. It also remains to be determined if postnatal care at home can be made as effective and cost-effective as similar care provided by health facilities.1414 WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014. We need both community-level interventions to promote the use of postnatal care services and health systems interventions to improve the supply of affordable and quality services – including, but not limited to, alleviation of user-fees and the promotion of postnatal care by health professionals. Strengthening the effectiveness and responsiveness of systems for health-care delivery6868 Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s Framework for Action. Geneva: World Health Organization; 2007. will also catalyse access to – and use of – postnatal and other obstetric care services. In the current and future elaboration of universal health coverage and equity schemes in low- and middle-income countries, due consideration should be provided to postnatal care services.

Acknowledgements

MVZ is also affiliated with the Department of Social and Preventive Medicine, University of Montreal, Quebec, Canada and the Public Health Research Institute, University of Montreal, Quebec, Canada. IK is also affiliated with the Research Centre of the University of Montreal Hospital Centre, Quebec, Canada and the Department of Social and Preventive Medicine, University of Montreal, Quebec, Canada.

Competing interests:

  • None declared.

References

  • 1
    Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014.
  • 2
    Dhaher E, Mikolajczyk RT, Maxwell AE, Krämer A. Factors associated with lack of postnatal care among Palestinian women: a cross-sectional study of three clinics in the West Bank. BMC Pregnancy Childbirth. 2008;8(1):26. doi: http://dx.doi.org/10.1186/1471-2393-8-26 PMID: 18638395
    » https://doi.org/10.1186/1471-2393-8-26
  • 3
    Ronsmans C, Graham WJ; Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet. 2006 Sep 30;368(9542):1189–200. doi: http://dx.doi.org/10.1016/S0140-6736(06)69380-X PMID: 17011946
    » https://doi.org/10.1016/S0140-6736(06)69380-X
  • 4
    Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al.; Lancet Every Newborn Study Group. Every Newborn: progress, priorities, and potential beyond survival. Lancet. 2014 Jul 12;384(9938):189–205. doi: http://dx.doi.org/10.1016/S0140-6736(14)60496-7 PMID: 24853593
    » https://doi.org/10.1016/S0140-6736(14)60496-7
  • 5
    Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank Estimates. Geneva: World Health Organization; 2012.
  • 6
    WHO technical consultation on postpartum and postnatal care. Geneva: World Health Organization; 2010.
  • 7
    Rahman MM, Haque SE, Zahan MS. Factors affecting the utilisation of postpartum care among young mothers in Bangladesh. Health Soc Care Community. 2011 Mar;19(2):138–47. PMID: 20880103
  • 8
    Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34. doi: http://dx.doi.org/10.1186/1471-2393-9-34 PMID: 19671156
    » https://doi.org/10.1186/1471-2393-9-34
  • 9
    Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007 Oct;85(10):812–9. doi: http://dx.doi.org/10.2471/BLT.06.035659 PMID: 18038064
    » https://doi.org/10.2471/BLT.06.035659
  • 10
    Fort AL. Coverage of post-partum and post-natal care in Egypt in 2005–2008 and Bangladesh in 2004–2007: levels, trends and unmet need. Reprod Health Matters. 2012 Jun;20(39):81–92. doi: http://dx.doi.org/10.1016/S0968-8080(12)39600-6 PMID: 22789085
    » https://doi.org/10.1016/S0968-8080(12)39600-6
  • 11
    Matijasevich A, Santos IS, Silveira MF, Domingues MR, Barros AJ, Marco PL, et al. Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health. 2009;9(1):335. doi: http://dx.doi.org/10.1186/1471-2458-9-335 PMID: 19751521
    » https://doi.org/10.1186/1471-2458-9-335
  • 12
    Abel Ntambue ML, Françoise Malonga K, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo–a case study of Lubumbashi City. BMC Pregnancy Childbirth. 2012;12(66):66. PMID: 22780957
  • 13
    Postpartum empowerment: an integrated approach driving demand and delivery of high quality, low-cost postnatal services in Kenya. Nairobi: Jacaranda Health Organization; 2012. Available from: http://savinglivesatbirth.net/summaries/162 [cited 2013 May 23].
    » http://savinglivesatbirth.net/summaries/162
  • 14
    WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014.
  • 15
    Opportunities for Africa’s newborns. Geneva: World Health Organization; 2006.
  • 16
    Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol. 2010 Apr;39 Suppl 1:i144–54. doi: http://dx.doi.org/10.1093/ije/dyq031 PMID: 20348117
    » https://doi.org/10.1093/ije/dyq031
  • 17
    Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women’s uptake of postpartum services. BJOG. 2005 Sep;112(9):1315–21. doi: http://dx.doi.org/10.1111/j.1471-0528.2004.00507.x PMID: 16101614
    » https://doi.org/10.1111/j.1471-0528.2004.00507.x
  • 18
    USAID/BASICS (Basic Support for Institutionalizing Child Survival) and the Prevention of Postpartum Hemorrhage Initiative. Integrated maternal and newborn care: supervisory and evaluation checklists. Arlington: United States Agency for International Development; 2009. Available from: http://www.basics.org/documents/Supervisory-and-Evaluation-Checklists_Newborn-Toolkit_BASICS.pdf [cited 2015 Jan 26].
    » http://www.basics.org/documents/Supervisory-and-Evaluation-Checklists_Newborn-Toolkit_BASICS.pdf
  • 19
    Crawley J. Reducing the burden of anemia in infants and young children in malaria-endemic countries of Africa: from evidence to action. Am J Trop Med Hyg. 2004 Aug;71(2) Suppl:25–34. PMID: 15331816
  • 20
    Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). Oxford: The Cochrane Collaboration; 2011. Available from: http://www.cochrane.handbook.org [cited 2015 Jan 6].
    » http://www.cochrane.handbook.org
  • 21
    Langlois EV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low- and middle-income countries. Syst Rev. 2013;2(1):55. doi: http://dx.doi.org/10.1186/2046-4053-2-55 PMID: 23830501
    » https://doi.org/10.1186/2046-4053-2-55
  • 22
    Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339 jul21 1:b2535. doi: http://dx.doi.org/10.1136/bmj.b2535 PMID: 19622551
    » https://doi.org/10.1136/bmj.b2535
  • 23
    Country and lending groups [Internet]. Washington: World Bank; 2014. Available from: http://data.worldbank.org/about/country-and-lending-groups [cited 2014 Jan 25].
    » http://data.worldbank.org/about/country-and-lending-groups
  • 24
    Rothman KJ, Greenland S, Lash TL. Modern epidemiology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
  • 25
    Quality assessment tool for quantitative studies. Hamilton: Effective Public Health Practice Project; 2013. Available from: http://www.ephpp.ca/tools.html [cited 2013 Mar 19].
    » http://www.ephpp.ca/tools.html
  • 26
    Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic reviews. Ann Intern Med. 1997 Nov 1;127(9):820–6. doi: http://dx.doi.org/10.7326/0003-4819-127-9-199711010-00008 PMID: 9382404
    » https://doi.org/10.7326/0003-4819-127-9-199711010-00008
  • 27
    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. doi: http://dx.doi.org/10.1136/bmj.327.7414.557 PMID: 12958120
    » https://doi.org/10.1136/bmj.327.7414.557
  • 28
    Viechtbauer W, Cheung MW-L. Outlier and influence diagnostics for meta-analysis. Res Synth Methods. 2010;1(2):112–25. doi: http://dx.doi.org/10.1002/jrsm.11
    » https://doi.org/10.1002/jrsm.11
  • 29
    Gumedze FN, Jackson D. A random effects variance shift model for detecting and accommodating outliers in meta-analysis. BMC Med Res Methodol. 2011;11(1):19. doi: http://dx.doi.org/10.1186/1471-2288-11-19 PMID: 21324180
    » https://doi.org/10.1186/1471-2288-11-19
  • 30
    Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10. doi: http://dx.doi.org/10.1186/1742-4755-8-10 PMID: 21539744
    » https://doi.org/10.1186/1742-4755-8-10
  • 31
    Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10(31):31. doi: http://dx.doi.org/10.1186/1475-9276-10-31 PMID: 21801437
    » https://doi.org/10.1186/1475-9276-10-31
  • 32
    Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: a cross-sectional analysis. Int J Equity Health. 2010;9(9):9. doi: http://dx.doi.org/10.1186/1475-9276-9-9 PMID: 20361875
    » https://doi.org/10.1186/1475-9276-9-9
  • 33
    Anson O. Utilization of maternal care in rural HeBei province, the People’s Republic of China: individual and structural characteristics. Health Policy. 2004 Nov;70(2):197–206. doi: http://dx.doi.org/10.1016/j.healthpol.2004.03.001 PMID: 15364149
    » https://doi.org/10.1016/j.healthpol.2004.03.001
  • 34
    Anwar I, Sami M, Akhtar N, Chowdhury ME, Salma U, Rahman M, et al. Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh. Bull World Health Organ. 2008 Apr;86(4):252–9. doi: http://dx.doi.org/10.2471/BLT.07.042754 PMID: 18438513
    » https://doi.org/10.2471/BLT.07.042754
  • 35
    Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43. doi: http://dx.doi.org/10.1186/1471-2393-9-43 PMID: 19754941
    » https://doi.org/10.1186/1471-2393-9-43
  • 36
    Baqui AH, Rosecrans AM, Williams EK, Agrawal PK, Ahmed S, Darmstadt GL, et al. NGO facilitation of a government community-based maternal and neonatal health programme in rural India: improvements in equity. Health Policy Plan. 2008 Jul;23(4):234–43. doi: http://dx.doi.org/10.1093/heapol/czn012 PMID: 18562458
    » https://doi.org/10.1093/heapol/czn012
  • 37
    Chakraborty N, Islam MA, Chowdhury RI, Bari W. Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study. Health Soc Care Community. 2002 Nov;10(6):492–502. doi: http://dx.doi.org/10.1046/j.1365-2524.2002.00389.x PMID: 12485137
    » https://doi.org/10.1046/j.1365-2524.2002.00389.x
  • 38
    Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. doi: http://dx.doi.org/10.1186/1471-2393-7-19 PMID: 17767710
    » https://doi.org/10.1186/1471-2393-7-19
  • 39
    Halder AK, Saha UR, Kabir M. Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004. World Health Popul. 2007 Apr;9(2):48–63. doi: http://dx.doi.org/10.12927/whp.2007.18853 PMID: 18270506
    » https://doi.org/10.12927/whp.2007.18853
  • 40
    Iyoke CA, Ifeadike CO, Nnebue CC, Onah HE, Ezugwu FO. Perception and care-seeking behaviour for post partum morbidity among mothers in Enugu south east, Nigeria. Niger J Med. 2011 Apr-Jun;20(2):260–5. PMID: 21970240
  • 41
    Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: http://dx.doi.org/10.1186/1475-9276-10-59 PMID: 22142036
    » https://doi.org/10.1186/1475-9276-10-59
  • 42
    Liu X, Zhou X, Yan H, Wang D. Use of maternal healthcare services in 10 provinces of rural western China. Int J Gynaecol Obstet. 2011 Sep;114(3):260–4. doi: http://dx.doi.org/10.1016/j.ijgo.2011.04.005 PMID: 21752373
    » https://doi.org/10.1016/j.ijgo.2011.04.005
  • 43
    Mahabub-Ul-Anwar M, Rob U, Talukder MN. Inequalities in maternal health care utilization in rural Bangladesh. Int Q Community Health Educ. 2006-2007;27(4):281–97. doi: http://dx.doi.org/10.2190/IQ.27.4.b PMID: 18573752
    » https://doi.org/10.2190/IQ.27.4.b
  • 44
    Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009 Sep;69(6):926–33. doi: http://dx.doi.org/10.1016/j.socscimed.2009.07.008 PMID: 19656604
    » https://doi.org/10.1016/j.socscimed.2009.07.008
  • 45
    Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Educ Res. 2007 Apr;22(2):166–76. doi: http://dx.doi.org/10.1093/her/cyl060 PMID: 16855015
    » https://doi.org/10.1093/her/cyl060
  • 46
    Okafor CB. Availability and use of services for maternal and child health care in rural Nigeria. Int J Gynaecol Obstet. 1991 Apr;34(4):331–46. doi: http://dx.doi.org/10.1016/0020-7292(91)90602-2 PMID: 1674481
    » https://doi.org/10.1016/0020-7292(91)90602-2
  • 47
    Ram F, Singh A. Is antenatal care effective in improving maternal health in rural Uttar Pradesh? Evidence from a district level household survey. J Biosoc Sci. 2006 Jul;38(4):433–48. doi: http://dx.doi.org/10.1017/S0021932005026453 PMID: 16762083
    » https://doi.org/10.1017/S0021932005026453
  • 48
    Sarma S, Rempel H. Household decisions to utilize maternal healthcare in rural and urban India. World Health Popul. 2007 Jan;9(1):24–45. doi: http://dx.doi.org/10.12927/whp.2007.18712 PMID: 18270498
    » https://doi.org/10.12927/whp.2007.18712
  • 49
    Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007 Sep;39(5):671–92. doi: http://dx.doi.org/10.1017/S0021932007001952 PMID: 17359562
    » https://doi.org/10.1017/S0021932007001952
  • 50
    Singh A, Padmadas SS, Mishra US, Pallikadavath S, Johnson FA, Matthews Z. Socio-economic inequalities in the use of postnatal care in India. PLoS One. 2012;7(5):e37037. doi: http://dx.doi.org/10.1371/journal.pone.0037037 PMID: 22623976
    » https://doi.org/10.1371/journal.pone.0037037
  • 51
    Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One. 2012;7(2):e31666. doi: http://dx.doi.org/10.1371/journal.pone.0031666 PMID: 22355386
    » https://doi.org/10.1371/journal.pone.0031666
  • 52
    Stupp PW, Macke BA, Monteith R, Paredez S. Ethnicity and the use of health services in Belize. J Biosoc Sci. 1994 Apr;26(2):165–77. doi: http://dx.doi.org/10.1017/S0021932000021209 PMID: 8014173
    » https://doi.org/10.1017/S0021932000021209
  • 53
    Tang J, Li NX. Use of maternal health care services in poor regions in Sichuan. Sichuan Da Xue Xue Bao Yi Xue Ban. 2008 Nov;39(6):1004–6. Chinese. PMID: 19253847
  • 54
    Zere E, Tumusiime P, Walker O, Kirigia J, Mwikisa C, Mbeeli T. Inequities in utilization of maternal health interventions in Namibia: implications for progress towards MDG 5 targets. Int J Equity Health. 2010;9(1):16. doi: http://dx.doi.org/10.1186/1475-9276-9-16 PMID: 20540793
    » https://doi.org/10.1186/1475-9276-9-16
  • 55
    Countdown to 2015. Maternal, newborn & child survival. Building a future for women and children. The 2012 report. Geneva: World Health Organization; 2012. Available from: http://www.countdown2015mnch.org/documents/2012Report/2012-complete-no-profiles.pdf [cited 2015 Jan 26].
    » http://www.countdown2015mnch.org/documents/2012Report/2012-complete-no-profiles.pdf
  • 56
    Chatterjee A, Paily VP. Achieving millennium development goals 4 and 5 in India. BJOG. 2011 Sep;118 Suppl 2:47–59. doi: http://dx.doi.org/10.1111/j.1471-0528.2011.03112.x PMID: 21951502
    » https://doi.org/10.1111/j.1471-0528.2011.03112.x
  • 57
    Abbas AA, Walker GJ. Determinants of the utilization of maternal and child health services in Jordan. Int J Epidemiol. 1986 Sep;15(3):404–7. doi: http://dx.doi.org/10.1093/ije/15.3.404 PMID: 3771079
    » https://doi.org/10.1093/ije/15.3.404
  • 58
    Titaley CR, Dibley MJ, Roberts CL. Factors associated with non-utilisation of postnatal care services in Indonesia. J Epidemiol Community Health. 2009 Oct;63(10):827–31. doi: http://dx.doi.org/10.1136/jech.2008.081604 PMID: 19414443
    » https://doi.org/10.1136/jech.2008.081604
  • 59
    Mullany LC, Lee CI, Yone L, Paw P, Oo EK, Maung C, et al. Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma. PLoS Med. 2008 Dec 23;5(12):1689–98. doi: http://dx.doi.org/10.1371/journal.pmed.0050242 PMID: 19108601
    » https://doi.org/10.1371/journal.pmed.0050242
  • 60
    Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues. 2012 Jul-Aug;22(4):e407–14. doi: http://dx.doi.org/10.1016/j.whi.2012.05.001 PMID: 22749200
    » https://doi.org/10.1016/j.whi.2012.05.001
  • 61
    Navaneetham K, Dharmalingam A. Utilization of maternal health care services in Southern India. Soc Sci Med. 2002 Nov;55(10):1849–69. doi: http://dx.doi.org/10.1016/S0277-9536(01)00313-6 PMID: 12383469
    » https://doi.org/10.1016/S0277-9536(01)00313-6
  • 62
    LeVine RA, LeVine SE, Rowe ML, Schnell-Anzola B. Maternal literacy and health behavior: a Nepalese case study. Soc Sci Med. 2004 Feb;58(4):863–77. doi: http://dx.doi.org/10.1016/S0277-9536(03)00261-2 PMID: 14672599
    » https://doi.org/10.1016/S0277-9536(03)00261-2
  • 63
    Guliani H, Sepehri A, Serieux J. What impact does contact with the prenatal care system have on women’s use of facility delivery? Evidence from low-income countries. Soc Sci Med. 2012 Jun;74(12):1882–90. doi: http://dx.doi.org/10.1016/j.socscimed.2012.02.008 PMID: 22483706
    » https://doi.org/10.1016/j.socscimed.2012.02.008
  • 64
    Addai I. Determinants of use of maternal-child health services in rural Ghana. J Biosoc Sci. 2000 Jan;32(1):1–15. PMID: 10676056
  • 65
    Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al.; Lancet Maternal Survival Series steering group. Going to scale with professional skilled care. Lancet. 2006 Oct 14;368(9544):1377–86. doi: http://dx.doi.org/10.1016/S0140-6736(06)69382-3 PMID: 17046470
    » https://doi.org/10.1016/S0140-6736(06)69382-3
  • 66
    Meshram II, Kodavanti MR, Chitty GR, Manchala R, Kumar S, Kakani SK, et al. Influence of feeding practices and associated factors on the nutritional status of infants in rural areas of Madhya Pradesh state, India. Asia Pac J Public Health. 2013 May 10; [Epub ahead of print]. doi: http://dx.doi.org/10.1177/1010539513486174 PMID: 23666834
    » https://doi.org/10.1177/1010539513486174
  • 67
    Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. A basic introduction to fixed effect and random effects models for meta-analysis. Res Synth Methods. 2010;1(2):97–111. doi: http://dx.doi.org/10.1002/jrsm.12
    » https://doi.org/10.1002/jrsm.12
  • 68
    Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s Framework for Action. Geneva: World Health Organization; 2007.

History

  • Received
    04 May 2014
  • Reviewed
    21 Dec 2014
  • Accepted
    04 Jan 2015
  • Issue publication
    Apr 2015
Creative Common -
This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.
World Health Organization Genebra - Genebra - Switzerland
E-mail: bulletin@who.int