Introduction
A profound event that significantly has far-reaching implications for the health and well-being of women is childbirth. According to estimates, over 40% of all pregnancies may experience some form of complication [
1]. The availability of emergency obstetric treatment inside healthcare facilities and the presence of trained birth attendants (TBAs) are acknowledged as critical components in lowering the incidence of maternal and neonatal mortality rates globally. Therefore, it is most convenient for a woman to give birth in a health facility where any problems that may arise are quickly resolved [
1‐
6].
Maternal and child health is a major concern in many low- and middle-income countries (LMICs), with a focused commitment to enhancing access to skilled birth attendance and reducing maternal and neonatal mortality rates [
7]. One of the pivotal determinants of maternal and neonatal health outcomes hinges on the choice of place of delivery [
8]. However, many women in the reproductive age in LMICs continue to experience challenges in obtaining and using maternal healthcare services such as pregnancy and delivery. As a result, they choose to give birth at home with the help of a TBA rather than in a health facility under the supervision of a skilled health professional [
9,
10].
Health facility delivery, often overseen by skilled birth attendants, is considered the cornerstone of safe motherhood practices globally [
2‐
4]. This choice ensures access to timely medical interventions capable of addressing complications during childbirth, thereby reducing the risks of maternal and neonatal mortality. However, the decision to give birth at a healthcare facility is determined by a complex interaction of sociodemographic, economic, cultural, and healthcare system-related variables [
3,
5,
6].
Over the last two decades, Madagascar’s maternal mortality ratio (MMR) has dropped from 658 to 392 deaths per 100,000 live births [
11,
12]. Previous studies and surveys, however, have highlighted obstetric issues caused by home births supported by TBAs, low health insurance subscriptions, and insufficient medical staff and equipment as the major reasons for the high MMR in Madagascar [
13]. As a result, maternal mortality in Madagascar continues to be a public health issue [
14]. Access to health care facilities, on the other hand, remains a serious challenge in Madagascar, where health staff are unevenly dispersed and the majority of people live in extremely rural and difficult-to-reach locations with poor road and communication networks [
15].
This study examined the predictors of health facility delivery in Madagascar, drawing from the wealth of data painstakingly collected through the Madagascar Demographic and Health Survey (MDHS). By delving into the intricate web of factors underpinning this pivotal choice, this research seeks to contribute significantly to the discourse on maternal and child health within the context of Madagascar. Furthermore, this study will provide key evidence that can be used by policymakers and program managers to design and implement interventions tailored to increasing the prevalence of health facility deliveries and ameliorating overall maternal and neonatal outcomes.
Discussion
Health facility delivery has been identified as one of the most effective methods for achieving the SDG which seeks to reduce maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030 [
15,
32]. Globally, the prevalence of health facility delivery was 76% and 56% for SSA as of 2018 [
33]. The prevalence of health facility delivery among women in Madagascar was found to be 41.2% in this analysis. This implies that the prevalence of health facility delivery is low among women in Madagascar. The prevalence found in this study is higher than the prevalence of 26.2% in Ethiopia [
34], 28.7% in Bangladesh [
35], and 41% in Nigeria [
36]. However, the prevalence of health facility delivery in this study is lower than 66% in SSA [
27], 82.7% in Southeast Ethiopia [
37], and 87.4% in East Africa [
28]. The possible explanation for the low prevalence of health facility delivery could be that Madagascar women may not be able access the majority of healthcare facilities due to distance and cost. Studies in Madagascar have revealed that less than 10% of women in Madagascar have health insurance, and more than half (51%) of health facilities in Madagascar have only a caregiver. Also, one in two health facilities is inaccessible year-round. Another explanation could be that 25.8% of women in Madagascar reside more than 5 km from the nearest healthcare facility, which is either understaffed or lacks sufficient medical care equipment and supplies [
13,
38‐
41].
In the multilevel analysis, model 3 was the best fit for discussion. Model 3 had the lowest ICC of 21.3% and AIC of 9,709.52. The results from the multilevel analysis of this study were similar to previous studies conducted in Eritrea [
10], SSA [
27], Bangladesh [
35], East Africa [
28,
42,
43], south-Asian countries [
44], and West Africa [
45,
46].
The study revealed that individual-level variables including age, educational level, marital status, parity, ANC visits, mass media exposure, religion, and wealth were significantly associated with health facility delivery in Madagascar. Our study revealed that older women were more likely to choose health facility delivery as compared to younger mothers. This finding is in line with other studies conducted in Nigeria [
36] and northern and south-central Ethiopia [
47]. However, other studies conducted in northwest Ethiopia [
48] and southern Ethiopia [
49] were inconsistent with our study. One possible explanation is that older women are more aware of the obstetric complications associated with age and hence choose health facility delivery [
47].
Several studies have shown that formal education influences women’s ability to make decisions about their reproductive health in SSA [
27,
50,
51]. It was found that the odds of choosing a health facility delivery increase with an increase in women’s educational level. This finding is consistent with the findings of studies conducted in SSA [
27], Ethiopia [
42,
43], rural Ghana [
45], Nepal [
52], and Nigeria [
4]. This reason could be attributed to the fact that formal education empowers and provides women with autonomy through the provision of essential information needed to deliver at a health facility during pregnancy. This essential information on reproductive health decisions safeguards the health of women and babies [
27,
43,
50,
53].
Another important factor that influenced the choice of place of delivery is the marital status of women in Madagascar. It was found that women who were either married or had been married were more likely to utilize health facilities during delivery compared to women who were never in union. The finding is in line with previous studies conducted in East Africa [
28,
54]. In contrast, studies conducted in southern Ethiopia [
49] and Ghana [
22] reported no statistically significant association between health facility delivery and marital status. The possible reason could be that women who are either married or have been married may receive spousal and family support in making health care decisions about maternal health service utilisation [
54].
Irrespective of how many times women have given birth, they are advised to have their babies delivered in health facilities [
32]. However, this current study found that the odds of health facility delivery women in Madagascar decrease with an increase in parity. The finding reveals that women with two or more births were less likely to opt for health facility delivery than those with one birth. This is consistent with studies conducted in Ghana [
45], Uganda [
55], and SSA [
24,
26]. Studies have argued that primiparous women access health facilities more frequently because they are more susceptible to maternal complications during child delivery than multiparous women [
56,
57]. Another plausible reason could be the financial burden associated with larger family sizes and the maternal experiences of women with more than one birth [
24,
26].
Another important predictor of health facility delivery in Madagascar was antenatal care visits. It was found that women who had at least an ANC visit were more likely to utilize health facilities during delivery. The finding is in line with previous studies conducted in Asia [
44,
52], Eastern Africa [
34,
58], and SSA [
24,
27,
59]. The reason could be that during ANC visits, women are most likely to be informed about the benefits associated with health facility delivery [
43,
60].
The other most significant predictor of health facility delivery among women in Madagascar was mass media exposure. Women who were exposed to mass media had higher odds of health facility delivery than those who were not exposed to mass media. This finding was supported by previous studies conducted in SSA [
27], Ghana [
61,
62], and Ethiopia [
63]. This reveals the positive influence of mass media on the choice of health facility delivery among women of reproductive age [
27].
Religion also played an essential role for women in choosing a place of delivery [
64]. Our finding, which shows that women affiliated with traditional religions had a lower likelihood of using health facilities during delivery compared to Christian women, confirms studies conducted in Ghana [
22,
65]. Women who hold traditional and other beliefs may be less likely to give birth in a health facility due to their disapproval of contemporary medical procedures. These women may assume that pregnancy and labour are natural biological processes that do not need medical treatment until an emergency occurs [
22].
Financial restrictions on access to and use of health care are pervasive in SSA, preventing many people, particularly the poor, from using health services [
27]. In this current study, it was revealed that household wealth plays an important role in choosing the place of delivery during pregnancy. Consistent with previous studies conducted in Eastern Africa [
28,
32,
34,
42], rural Ghana [
45], and SSA [
24,
26], this study confirms that health facility delivery among women in Madagascar increases with increasing wealth status. The plausible reason could be that the richest women can afford the necessary medical and transportation expenditures, which may improve their health-seeking behaviour and autonomy [
34].
Furthermore, distance to health facilities, community literacy level, and community socioeconomic status were the community-level variables found to be significantly associated with women’s health facility delivery in Madagascar.
Another significant predictor of health facility delivery in this study was distance to the facility. The analysis revealed that distance to health facilities was not a big problem for women in Madagascar. This finding is consistent with studies conducted in the SSA [
26] and East Africa [
28]. This could be as a result of affordable and reliable transportation that can mitigate the impact of the distance [
22]. It emphasizes how important it is to give the population access to maternal health care services [
28].
The study revealed that community literacy level was an important determinant of health facility delivery among women in Madagascar. From the analysis, women who lived in communities with high literacy level in Madagascar were more likely to deliver in a health facility than their counterparts who lived in communities with low literacy level. The result from this current study is in line with a previous study conducted in SSA [
24]. A plausible reason could be that educated women may have adequate material resources to access healthcare services [
24].
The study found that community socioeconomic status has an effect on the choice of place of delivery. The finding was consistent with previous research conducted in SSA [
24], Ghana [
66], and Bangladesh [
67], where women of high community socioeconomic status had higher odds of health facility delivery. This might be due to the availability of healthcare facilities within their range as well as their financial ability to obtain and use health care facilities [
67].
Strengths and limitations of the study
This study’s major strength is the use of current nationally representative data from the MDHS, which makes the study’s findings generalizable to women of reproductive age in Madagascar. Another strength is the rigorous analytical and statistical approach used to increase the dependability of our findings by estimating the cluster effect on health facility delivery. Despite these strengths, there are a few limitations inherent in this study. First, the research sample was confined to women of reproductive age (15–49) who had at least a birth five years prior to the survey. Moreover, the cross-sectional character of the MDHS and the causal-effect relationship could not be determined. Furthermore, recollection bias may affect survey participants’ self-reported data, which could lead to over- or under-reporting.
Conclusion
The prevalence of health facility delivery in Madagascar is low in this current study. The Ministry of Public Health and its agencies ought to consider women’s age, women’s educational level, parity, marital status, ANC visits, mass media, religion, wealth, community literacy level, and community socioeconomic status when developing strategies to improve health facility delivery in Madagascar. The findings of this study call on stakeholders and the government to strengthen the health system of Madagascar using the framework for universal health coverage (UHC). There is also the need to implement programmes and interventions geared towards increasing health facility delivery among young adults, women with no formal education, and women with at least two births. Also, consideration should be made to provide free maternal health care and a health insurance scheme that can be accessed by women in the poorest wealth index. Finally, there is the need for further studies to consider involvement of family members in decision-making about place of delivery.
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