Background. Pregnant women need adequate antenatal care (ANC) and delivery care fortheir own health and for healthy children. Availability of such care has increased in Vietnam but maternal mortality remains high and variable between population groups. Aims. The general aim of this thesis is to describe and discuss the use of antenatal and delivery care in relation to demographic and socio-economic status and other factors in two health and demographic surveillance sites (HDSS), one rural and one urban. One specificaim of the thesis is to present experiences of running the urban HDSS. Methods. Between April 2008 and December 2009, 2,757 pregnant women were identifiedin the sites. Basic information was obtained from 2,515 of these. The use of ANC was followed to delivery for 2,132. Three indicators were used. ANC was considered overall adequate if the women started ANC within the first trimester, used three or more visits and received all the six recommended core services at least once during pregnancy. Delivery care was studied for all the 2,515 women. Main Findings. Nearly all 2,132 participants used ANC. The mean numbers of visits were 4.4 and 7.7 in the rural and urban areas. Mainly due to less than recommended use of core ANC services, overall ANC adequacy was low in some groups, particularly in the rural area (15.2%). The main risk factors for not having adequate ANC were (i) living in a rural area,(ii) low level of education, (iii) low economic status and (iv) exclusive use of private ANC providers. Rural women accessed ANC mainly at commune health centers and private clinics. Urban women accessed ANC and gave birth at central hospitals and provincial hospitals. Caesarean section (CS) was common among urban women (38.5%). Good socioeconomic condition and male babies were associated with delivery in hospitals and CS births. Almost all women had one or more antenatal ultrasound examination, the mean was about 4.5. Rural women spent 3.0% and 19.0% of the reported annual household income percapita for ANC and delivery care, respectively, compared to 6.1% and 20.6% for urbanwomen. The relative economic burden was heaviest for poor rural women. Conclusion. The coverage of ANC was high in both contexts but with large variations between population subgroups. The major concerns are that poor women in the rural area received incomplete services according to recommendations and that many women, particularly the well-off, in the urban area appeared to overuse technology, ultrasound scanning, delivery in highlevel health care and CS delivery. National maternal healthcare programs should focus on improving ANC service content in rural areas and controlling technology preference in urban. The pregnant women with relatives and friends as well as ANC providers share the responsibility for a positive development. All parties involved must be targeted to improve knowledge, attitudes and practices.

Introdução: A educação para a promoção da saúde no pré-natal deve ser oferecida baseada nas necessidades e avaliações das próprias gestantes. A cartilha educativa Celebrando a Vida deve ser disponibilizada como parte da assistência pré-natal em função dos resultados que pode proporcionar às gestantes. Objetivo Geral: Avaliar os efeitos da cartilha educativa Celebrando a Vida na assistência pré-natal. Método: O método foi quantitativo e o tipo de estudo foi de intervenção, longitudinal, prospectivo, controlado e não paralelo. Locais de estudo: O estudo foi realizado em duas UBS do distrito de saúde do Butantã, em São Paulo: UBS Jd. Jaqueline e a UBS Jd. São Jorge. A população do estudo foi composta por gestantes em acompanhamento pré-natal, na UBS Jd. Jaqueline: grupo controle (sem cartilha) e grupo intervenção (com cartilha), e na UBS Jd. São Jorge: grupo controle (Curso do Pré-natal sem cartilha) e grupo intervenção (Curso do Pré-natal com cartilha). A coleta de dados foi realizada em três momentos: inicial, intermediário e seguimento. Os instrumentos utilizados foram: o questionário Sociodemográfico e Obstétrico, a escala de Qualidade de Vida Ferrans e Powers Quality of Life Index para gestantes e o Formulário de Avaliação da Educação sobre Gravidez durante o Pré-Natal. Análise de Dados: Qui-quadrado, Análise de Variância para Medidas Repetidas (ANOVA), Testes-t, Mann-Whitney e Wilcoxson. Resultados: 135 gestantes participaram do estudo na avaliação inicial, 126 no momento intermediário e 111 no seguimento. As informações recebidas durante o pré-natal foram avaliadas como suficientes pelo grupo intervenção da UBS Jd. Jaqueline após a entrega da cartilha, passando de 69,6% no momento inicial para 87,5% no seguimento. Na UBS Jd. Jaqueline, o conjunto representado por família, amigos e vizinhos foi o recurso mais citado no momento inicial para os dois grupos (76,6% controle, 57,4% intervenção). Após a intervenção, a cartilha foi o recurso mais citado para o grupo intervenção (68,2% no momento intermediário e 70,0% no seguimento). Na UBS Jd. São Jorge, o conjunto família, amigos e vizinhos foi o mais citado no momento inicial para os dois grupos (77,8% controle, 65,2% intervenção). No momento intermediário, os profissionais de saúde foram os mais citados (94,1% controle e 80,0% intervenção) enquanto a cartilha correspondeu a 75%. Na UBS Jd. Jaqueline e na UBS Jd. São Jorge, 100% das gestantes haviam lido a cartilha ou parte dela no seguimento. Mais de 70% das gestantes perceberam um aumento do conhecimento após ler a cartilha. Houve aumento significativo na qualidade de vida das gestantes da UBS Jd. São Jorge no momento intermediário. Conclusão: Houve resposta positiva à cartilha nas duas unidades. As gestantes leem a cartilha - mesmo aquelas com experiência de gestação anterior, utilizam as informações, são ajudadas pelo conteúdo da cartilha e também percebem mudança na vida. O uso da cartilha associada ao Curso do Pré-Natal aumenta a QV das gestantes em relação ao domínio socioeconomico. / Introduction: Antenatal education should be based on client`s needs and their evaluations. The booklet Celebrating Life must integrates antenatal care in function of its outcomes. General Objective: To evaluate the effects of the educational booklet Celebrating Life. Method: It was quantitative and the study design was an intervention, longitudinal, prospective, controlled and unparallel. Two public health units, Units Jaqueline and Sao Jorge in Sao Paulo City, Brazil were the settings. The studied population was composed of pregnant women receiving antenatal care, according to the groups at Unit Jaqueline: group control (without the booklet) and group intervention (with the booklet), and at Unit Sao Jorge: group control (Antenatal Care Course without the booklet) and group intervention (Antenatal Care Course with the booklet). The data collection was done in three moments: baseline, intermediate time and follow-up. The instruments used were: a Sociodemography and Obstetric Questionnaire, The Ferrans e Powers Quality of Life Index (QLI for Brazilian pregnant women) and a Form of Assesment of Pregnancy Education during Antenatal Care. Data Analysis: Chi-square, Variance Analysis for Repeated Measures (ANOVA) and Paired Sample Statistics Mann-Whitney and Wilcoxson. Results: 135 pregnant women participated in this study at baseline, 126 intermediate time and 111 at follow-up. Group intervention in Unit Jaqueline considered they received enough antenatal information on intermediate time (69.6%) and follow-up (87.5%) than group control. The sources of information were different between groups. At Unit Jaqueline, the booklet became most cited source for group intervention (68.2% intermediate time and 70.0% on follow-up). At Unit Jaqueline, family, friends and neighbours were more cited source at baseline for both groups (76.6% control, 57.4% intervention) at baseline. At intermediate time and follow-up, the booklet was the most cited source by the intervention group (68.2% intermediate time and 70.0% follow-up). At Unit Sao Jorge, family/friends and neighbors were most cited (77.8% control, 65.2% intervention) on baseline. At intermediate time, health providers were most cited until follow-up (94.1% control and 80.0% intervention) and the booklet corresponded to 75%. All pregnant women of both Units read all booklet or part on follow-up. More than 70% of pregnant women had an increase in knowledge after read the booklet. There was a significant increase on quality of life of pregnant women at Unit Sao Jorge after intervention. Conclusion: There was a positive response to the booklet at both units. Booklet is a source of information that pregnant women who received it individualy use most for their doubts. Pregnant women read the booket, even those who had previous experience of pregnancy, they use booklet`s information, are helped by it and realize changes in life. The booklet associated with Antenatal Care Course increases quality of life of pregnant women related to socio-economic domain.

Magister Public Health - MPH / Since the introduction in 2005 of prevention of mother-to-child transmission of HIV (PMTCT) services in Akwa Ibom State in Nigeria the PMTCT programme has faced several challenges including that of poor male participation in the PMTCT programme. To date no research has focused on the issue of male participation in PMTCT programmes in Akwa Ibom State, and there is thus a limited understanding of why so few male partners of HIVpositive pregnant women participate in the State's PMTCT programme. It is therefore important to explore the factors affecting male involvement in PMTCT programmes in Akwa Ibom State, so that strategies can be put in place to help improve the overall health of their families and themselves. The overall aim of the study was thus to explore the factors affecting male participation in the PMTCT programme at a primary health care center in West Itam, Akwa Ibom State, in Nigeria. This explorative study was conducted using a descriptive qualitative research approach. The research study approach helped to understand the perspectives of the male partners of HIV positive pregnant women who received the PMTCT intervention, as well as key informants in the Primary Health Care (PHC) facility where these PMTCT services are offered. The study population consisted of all males living within the catchment area of the West Itam PHC, Akwa Ibom State, Nigeria. In the research study, 11 men were purposively sampled: five of whom were the partners of HIV-positive women who had attended, or were currently attending the PMTCT services at the West Itam PHC with their partner. The other six interviewees were local male community members – who would be eligible to potentially accompany their partner to PMTCT services at the facility. The data was collected through individual, in-depth interviews with the male partners and community members using a semi-structured interview guide. One focus group discussion (FGD) was conducted with key personnel working in the West Itam PHC using a semistructured interview guide. All interviews and the FGD were tape-recorded and transcribed. Thematic analysis was used to analyse the data. Ethical approval was first obtained from the UWC Research Ethics Committee and the Ethics Committee of the Akwa Ibom State Ministry of Health before proceeding with the study. From this study, it is suggested that most of the respondents knew that PMTCT services are offered at the PHC West Itam. They knew their partner's next antenatal appointment, but only very few accompany their pregnant partners to the antenatal clinic. The striking reason being a lack of time/being busy. The key means of support of the partners' antenatal visits was giving their pregnant partners money for transport, and money for food/snacks (at the clinic). Inter-spousal communication was found to be good, and there appeared to be a perception by the men that antenatal clinic (ANC)/PMTCT is not only for women, with most of the men agreeing that it is useful for men to participate in PMTCT. The barriers to male participation in the PMTCT programme that were elicited in this study include lack of belief about HIV/AIDS and lack of awareness about PMTCT and the perception of PMTCT as a "women's affair". Another barrier to male participation in the PMTCT programme was the men being busy with their jobs/lack of time, and fear. Facility-based barriers include delays/time wasting at the clinic, and the nurses, who were identified as having an unaccommodating attitude towards the clients. Finally, the fact that the nurses and counsellors at the PHC West Itam were all female was a problem for men. It is recommended that there is need for advocacy and education to raise awareness about HIV/AIDS, and encourage male participation in PMTCT. It is also important to encourage the disclosure of HIV status by the women to their male partners. Furthermore, a separate male counselling unit needs to be created, as well as ensuring the employment of male nurses and counsellors. Additionally, the female nurses at the facility need to be trained/re-trained on proper attitude and confidentiality, and efforts must be made to avoid delays at the clinic.

Magister Public Health - MPH / Globally, approximately 600,000 infants each year are born with HIV infection in Sub-Saharan Africa as a result of mother to child transmission (MTCT) (UNAIDS, 2001). Whereas there is significant progress in reduction of mother to child transmission of HIV in Uganda, the Western Region of Uganda has low rates of PMTCT service utilization. The progress has been hampered by many factors including low male involvement (MOH, 2005). The main objective of this study was therefore to identify some of the factors that discourage men from participating in PMCT services in this region. The study was conducted in Kibaale District in the Western Region of Uganda for a period of one month in mid 2009. Data was collected using a qualitative methodology. The tools that were used for data collection were key informant in-depth interviews and focus group discussions (FGDs) guides. Data was collected from PMTCT service providers, women of reproductive age group and men whose partners had given birth during the last year (2008). For the focus groups, a purposive sample of men and women who had some children born in 2008, followed by random sampling from the list of potential subjects was used to select participants. The study sample comprised of three FGDs of women who had given birth in year 2008 and male partners of women who had also given birth in 2008. Each FGD consisted of eight participants. One FGD was with women only, the other with men only, while the third was with both men and women.

Maternal mortality is a critical area of concern globally, despite the availability of accessible preventive measures. The role of sociodemographic and service delivery factors in maternal mortality in the Accra Metropolitan Area of Ghana are important to examine. As part of the United Nations (UN) Millennium Campaign, the UN implemented 8 Millennium Development Goals (MDGs); maternal mortality reduction by 75% between 1990 and 2015 was among the fundamental MDGs to be achieved by 2015. The purpose of this case-control study was to use secondary data to assess the relationships between sociodemographic variables, service delivery factors, and maternal mortality among 8,171 women of reproductive age (15-45 years) living in the Greater Accra metropolitan area in Ghana. The health belief model and social cognitive theory provided the theoretical framework to interpret the study findings. Particularly, income (p = .023), primary (p = .035) and secondary (p = .002) education, and health insurance (p = .008) were significantly associated with maternal-related mortality. However, for survival outcome, health insurance (p = .003), prenatal care (p = .001), and presence of a skilled attendant at delivery (p = .020) were significant factors. These study results provide support for the significant effects of sociodemographic and service delivery factors on maternal mortality and survivorship in the Greater Accra metropolitan area in Ghana. The results of this study could enhance educational and outreach programs designed to lower maternal mortality rate. Further research needs to be done to advance knowledge and practice in health delivery services and public health education with respect to the importance of sociodemographic and service delivery characteristics.

This thesis investigates the utilisation of maternal health care in Zambia, where despite being a signatory to the Safe Motherhood Initiative and Millennium Development Goals, which are aimed at improving maternal health, indicators of maternal health continue to perform poorly. The need to understand crucial factors in improving maternal health motivated the current research, especially since there is a dearth of literature in this area in Zambia. The thesis focuses on two aspects of maternal health care: antenatal care (ANC) and facility-based deliveries, to answer two broad questions. Firstly, what factors determine the use of ANC in Zambia? Secondly, to what extent has the abolition of user fees affected facility-based deliveries? An assessment of the factors, which explain the utilisation of ANC in Zambia, using three sets of comparable datasets reveals that, while there are differences in the factors explaining the decision to use ANC and the frequency of visits over time, the decision to seek ANC and the frequency of use is low among the poor and less educated, and there are marked regional differences in utilisation. The most appropriate econometric specification for antenatal visits, according to different performance indicators, was the two-part model, which differs from recent research favouring more complex methodologies. The analysis is further extended through the inclusion of supply-side factors and the examination of individual and community level factors associated with inadequate and non-use of ANC, following the adoption of the focused ANC approach in Zambia. To incorporate the supply side factors, the 2007 Zambia Demographic and Health Survey was linked to administrative and health facility census data using geo-referenced data. To assess the factors associated with (1) the inadequate use of ANC (defined as three or less visits), and (2) the non-use of ANC in the first trimester of pregnancy, we specify two multilevel logistic models. At the individual level, the woman’s employment status, quality of ANC received and the husband’s educational attainment are negatively associated, while parity, the household childcare burden and wealth are positively associated with inadequate utilisation of ANC. Both individual and community level characteristics influence inadequate use and non-use of ANC in the first trimester; however, community level factors are relatively stronger in rural areas. Although ANC is an important facet of maternal care, it occurs before delivery, but does not necessarily provide much information with respect to delivery decisions. Therefore, the thesis investigates delivery decisions, as well, in particular, the effect of user fee removal in rural areas of Zambia on facility-based deliveries. To account for regional differences, we employ a Seemingly Unrelated Regression model incorporating an Interrupted Time Series design. The analysis uses quarterly longitudinal data covering 2003q1-2008q4. When unobserved heterogeneity, spatial dependence and quantitative supply-side factors are controlled for, user fee removal is found to immediately increase aggregate facility-based deliveries, although the national trend was unaffected. Drug availability and the presence of traditional birth attendants also influence facility-based deliveries at the national level, such that, in the short-term, strengthening and improving community-based interventions could increase facility-based deliveries. However, there is significant variation and spatial dependence masked in the aggregate analysis. The results highlight the importance of service quality in promoting facility-based deliveries, and also suggest that social and cultural factors, especially in rural areas, influence the use of health facilities for delivery. These factors are not easily addressed, through an adjustment to the cost of delivery in health facilities. Additionally, we analyse the effect of user fee abolition on the location of childbirth, focussing on deliveries that occur in public health facilities using household survey data. To elicit the causal relationship, we exploit the relative change in fees across health districts within a difference-in-differences framework. Surprisingly, although reductions in home deliveries were observed, as expected, reductions in public health facility-based deliveries were also uncovered, along with increases in deliveries at private health facilities. However, these findings were statistically insignificant; suggesting that the abolition of user fees had little, if any, impact on the choice of location for childbirth. The statistically insignificant, but unexpected, causal effects further suggest that the removal of user fees have unintended consequences, possibly the transference of facility costs to the client, which would deter the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in outcomes; instead, other efforts, such as improving service quality, could have a greater impact. / Thesis (PhD)--University of Pretoria, 2013. / gm2014 / Economics / unrestricted

Since 2006, Uganda has experienced a nonchanging neonatal mortality rate of 27 out of 1,000 live births, which is higher than the global average of 19 deaths for every 1,000 live births. The purpose of this retrospective cross-sectional study was to determine factors affecting access to health services and their impact on newborn deaths in Uganda. Mosley and Chen's model for child survival in developing nations provided the framework for the study. Secondary data from the 2016 demographic and health survey (UDHS) collected by the Uganda Bureau of Statistics (UBOs) was used. A total of 7,538 cases were used and analyzed using binary logistic regression and one-way analysis of covariance (ANCOVA). The results showed attending less than 4 antenatal care (ANC) visits during pregnancy increased the odds of neonatal deaths 1.57 times, while not taking antimalarial drugs during pregnancy increased the odds of neonatal deaths 1.67 times. However, receiving 4 or more tetanus toxoid (TT) vaccine doses before pregnancy was not statistically associated with an increased risk of neonatal death (p = .597). Also, there was no significant relationship between neonatal mortality and whether distance to health facilities was a challenge (p = .276) or receiving medical assistance during childbirth (p = .420). While there were significant differences in deaths of newborns in geographic regions while controlling for the number of ANC visits (p = .023), there were no differences while controlling for all three covariates, F(4, 117) = 2.00, p = .098. Findings may be used to inform government policies on ANC and malaria prevention during pregnancy, which may reduce neonatal mortality rates in Uganda.

Background: Female genital mutilation is a harmful cultural practice that is carried out in several places around the world, despite the fact that it is a violation of women’s human rights. Worldwide, around 200 million young girls and women live with the aftermath of genital mutilation. There are several motives for implementing the practice linked to social, cultural and esthetic aspects. Aim: To describe how women who have been circumcised experience antenatal–and maternity care. Method: The study was designed as a general literature study which included nine scientific articles with a qualitative approach. Qualitative content analysis was applied. Result: Two categories and four subcategories emerged. “A confidence-building approach” and “Feeling trust in a female caregiver” went under “Good care relationship” while “Lack of knowledge about female genital mutilation” and “The feeling of being different” belonged to “Lack of empathy”. Conclusion: A confidence–building approach can demonstrably form the basis for a good care relation between a woman who has been circumcised and a healthcare professional. However, women who have been circumcised deliberately chose not to disclosure their health problems when they felt that healthcare professionals lacked knowledge about female genital mutilation. To alleviate the suffering and promote well–being of women who have circumcised, the healthcare professionals need to show respect, consideration and also provide caring care. / Bakgrund: Kvinnlig könsstympning är en skadlig kulturell sedvänja som utförs på flera håll runt om i världen trots att det är ett brott mot kvinnors mänskliga rättigheter. Globalt lever cirka 200 miljoner unga flickor och kvinnor i efterföljderna av könsstympning. Det finns flertal motiv till att genomföra kvinnlig könsstympning kopplad till sociala, kulturella samt estetiska aspekter. Syfte: Att beskriva hur kvinnor som blivit könsstympade upplever mödra–och förlossningsvården. Metod: Studien utformades som en allmän litteraturstudie med nio vetenskapliga artiklar med kvalitativ ansats. Kvalitativ innehållsanalys tillämpades. Resultat: Två kategorier och fyra subkategorier framkom. “Ett förtroendeingivande bemötande” och “Att känna tillit till en kvinnlig vårdgivare” gick under “God vårdrelation” medan “Bristande kunskaper kring kvinnlig könsstympning” och “Känslan att vara annorlunda” tillhörde “Brist på empati”. Slutsats: Ett förtroendeingivande bemötande kan bevisligen utgöra grunden för en god vårdrelation mellan kvinna som blivit könsstympad och sjukvårdspersonal. Dock valde kvinnor som blivit könsstympade avsiktligt att inte delge sina hälsoproblem när de ansåg sjukvårdspersonal sakna kunskaper om kvinnlig könsstympning. För att lindra lidandet och befrämja välbefinnandet hos kvinnor som blivit könsstympade skall hälso–och sjukvårdspersonal visa respekt, omtanke samt ge omsorgsfull vård.

Thesis (MPH.) -- University of Limpopo, 2021 / Background: South Africa’s poor maternal health indicators have resulted from weak maternal health services delivery, including access to quality family planning, skilled birth attendance, emergency obstetric care, and postnatal care for mothers and new-borns. Maternal deaths and disabilities remain a major public health problem in developing countries and maternal mortality is the health indicator which shows the greatest gap between the rich and poor countries. There are global achievements which are substantial reduction in global maternal mortality and an increase in the proportion of childbirths occurring in health facilities. On annual basis there are maternal health outcomes which occurs and these include an estimated 139 million births, an estimated 289 000 women die during pregnancy, childbirth or soon after and lastly an estimate 2.6 million will have stillbirths and 2.9 million infants will die in the first month of life. The purpose of the study was to determine the factors driving maternal health services utilization in rural areas of Limpopo Province. Methodology: The current study was done at Hlogotlou area in Sekhukhune district of Limpopo province and it used a quantitative research approach, that was descriptive cross-sectional study to determine the factors driving maternal health services utilization. The structured questionnaire was used to describe the knowledge levels of pregnant women on utilizing the antenatal services and to describe the utilization of prenatal services by pregnant women. The sampling method was random. The total number of 450 pregnant women participated in the study and all of them were analysed. Data were analysed using STATA version 12 and descriptive statistics were used to describe the data wherein categorical variables, frequencies and percentages were reported. Differences between groups (teenagers, adolescents, adults) were analysed using univariate logistic regression. Results: A total of 450 pregnant women were interviewed majority of women were in the age group 21-25 years, single, unemployed had a secondary educational level. Socio-economic status was assessed using a household wealth index and majority of the pregnant women in the current study were in the medium socio-economic status at 66.4% and majority of the women were using social grants 67.8%. Majority of women get information pertaining to antenatal care from televisions followed by those who v received information from leaflets, radio and those who did not receive information from anywhere at 37.1%, 23.1%, 22.7% and 16.9% respectively. There was a statistical significance difference between those who initiated first antenatal care visit before 12 weeks and after 12 weeks at p-value=0.007. Majority of pregnant women who used televisions as source of information for maternal health care, majority of them were found to be initiating antenatal care after 12 weeks at as compared to those who used radio and leaflets or newspapers as they initiated antenatal care before 12 weeks. Majority of pregnant women in the current study were aware of the antenatal care services rendered at the clinics and they were aware of the fact that antenatal care services rendered at the clinics could assist in detecting the complications related to pregnancies and also reported that these services could reduce the maternal and neonatal morbidity including maternal mortality. There was an understanding of the importance of antenatal care amongst the pregnant women. The predictors of utilization of maternal health services were young age, lower educational level pregnant women who were not married were pregnant women who were in the low socio-economic status. The young pregnant women were 2.2 times more likely to plan their pregnancies and 1.8 times more likely to discuss their pregnancies with their partners or spouses. Pregnant women who were married at a young age were 0.4 times less likely to lack the knowledge about existing for antenatal care at the clinics. Pregnant women with lower educational level were 6.8 times more likely to lack the knowledge about existing for antenatal care at the clinics. Pregnant women who were not married were 2.1 times more likely to go for the first antenatal care booking in the first trimester (1-12 weeks). Pregnant women who were in the low socio-economic status were 1.4 times more likely to lack the knowledge about existing for antenatal care at the clinics and 1.3 times more likely to report that barriers to accessing antenatal care services was either culture, religion or language barrier. Conclusion: The findings of this study highlight the need to address the structural socio-economic drivers of maternal health care utilizations in rural areas of Limpopo Province, South Africa. Timely entry to antenatal care was low in the study area. In order to improve the situation, it is important to provide community-based information, education and vi communication on antenatal care and its right time of commencement. In addition, empowering women and implementing the proclamation designed for the age at marriage should be mandatory up to the local level. Our findings suggested that policies enhancing improved education could benefit health awareness. Key concepts Antenatal care, maternal health care services, pregnant women, utilization.

Maternal Mortality Rate (MMR) in Ethiopia remains one of the highest in the world due in part to very limited use of maternal health services. However, the underlying factors for limited use of the services and hence the high MMR are not well known. The purpose of this study was to identify factors associated with use of maternal health services and maternal health risks, to analyze inequity patterns between use of maternal health services and maternal health risks, and to measure the magnitude and trends in inequity. Behavioral-cultural and structural theories of health inequalities were used to frame the study. Research questions included whether there were trends of inequity in use of maternal health services, if sociodemographic characteristics were associated with use of the services, and whether inequities in use of the services were associated with maternal health risks. The study design was quantitative and used data collected through Demographic and Health Surveys (DHS) conducted in 2000, 2005, and 2011. DHS had employed stratified 2-stage cluster design; this analysis used logistic regression method, odds ratio chi-square test, and correlation measures. The findings indicated statistically significant inequities on use of antenatal care and skilled birth attendant services associated with women's residence, level of education, income, administrative region, distance to a health facility, out-of-pocket payment for health services, and involvement in decision making. Based on the findings, it is recommended to design maternal health policies and programs that improve access and use of the services, specifically for women in rural areas, with no education and with limited economic capacity. Further research is also recommended for regions where sample size was limited. Maternal health policies and programs designed to reach the most disadvantaged women could increase service use and improve maternal health, leading to positive social change.