title: A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda.
abstract: Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors.
  
  
  
  We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique.
  
  
  
  A history of newborn death (aOR = 12.64, 95% CI 5.31-30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48-8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45-0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46-0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26-0.94) compared to being gravida one. Mother's age group, 20-24 (aOR = 0.24, 95% CI 0.08-0.75) and 25-29 years (aOR = 0.20, 95% CI 0.05-0.86) compared to 15-19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79-2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01-1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries.
  
  
  
  Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.
authors.affiliation: Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda. mk.rornald@yahoo.com.|Department of Planning and Applied Statistics, Makerere University School of Statistics and Planning, Kampala, Uganda. mk.rornald@yahoo.com.|Maternal and Newborn Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda. mk.rornald@yahoo.com.
authors.forename: Rornald Muhumuza
authors.initials: RM
authors.lastname: Kananura
authors.affiliation: Department of Planning and Applied Statistics, Makerere University School of Statistics and Planning, Kampala, Uganda.
authors.forename: Robert
authors.initials: R
authors.lastname: Wamala
authors.affiliation: Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ekirapa-Kiracho
authors.affiliation: Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.|Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Moses
authors.initials: M
authors.lastname: Tetui
authors.affiliation: Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Suzanne N
authors.initials: SN
authors.lastname: Kiwanuka
authors.affiliation: Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.|Global Health Division, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Maternal and Newborn Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: Department of Planning and Applied Statistics, Makerere University School of Statistics and Planning, Kampala, Uganda.
authors.forename: Leonard K
authors.initials: LK
authors.lastname: Atuhaire
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D004522:Educational Status; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D008423:Maternal Age; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D016017:Odds Ratio; D010298:Parity; D066087:Perinatal Death; D011247:Pregnancy; D018566:Pregnancy, High-Risk; D011295:Prenatal Care / Q000706:statistics & numerical data; D014454:Uganda; D055815:Young Adult
keywords: Interrelationship; Maternal health utilization; Newborn outcomes; Structural equation modeling