title: Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries.
abstract: Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. In this study, we explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH.
  
  
  
  Using Demographic and Health Surveys data of 12 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Full Information Maximum Likelihood estimation procedure which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions was adopted in LISREL 8.80. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model.
  
  
  
  Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from 'adequate antenatal care' to 'adequate delivery care' (0.32) and to 'adequate child's immunization' (0.36); from 'adequate delivery care' to 'adequate postnatal care' (0.78) and to 'adequate child's immunization' (0.15) were positively associated and statistically significant at p < 0.001. Only the path relationship from 'adequate postnatal care' to 'adequate child's immunization' (-0.02) was negatively associated and significant at p < 0.001.
  
  
  
  In conclusion, utilization of each level of MNCH care is related to the next level of care, that is - antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child's immunization program. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child's immunization program could serve towards improving maternal and infant health outcomes and equity.
authors.affiliation: International Health Program, Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Patrick Opiyo
authors.initials: PO
authors.lastname: Owili
authors.affiliation: Institute of Community Health and Development, Great Lakes University of Kisumu, Kisumu, Kenya.
authors.forename: Miriam Adoyo
authors.initials: MA
authors.lastname: Muga
authors.affiliation: Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan. yjchou@ym.edu.tw.
authors.forename: Yiing-Jenq
authors.initials: YJ
authors.lastname: Chou
authors.affiliation: School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
authors.forename: Yi-Hsin Elsa
authors.initials: YH
authors.lastname: Hsu
authors.affiliation: Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Nicole
authors.initials: N
authors.lastname: Huang
authors.affiliation: Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Li-Yin
authors.initials: LY
authors.lastname: Chien
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D002648:Child; D000067576:Child Health; D002662:Child Health Services; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data; D007223:Infant; D007231:Infant, Newborn; D016013:Likelihood Functions; D008427:Maternal Health Services / Q000706:statistics & numerical data; D000068101:Maternal-Child Health Services / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration; D012107:Research Design; D012111:Residence Characteristics; D055815:Young Adult
keywords: Continuum of care; Maternal, newborn and child health; Structural equation modeling; Sub-Saharan Africa