Exploration of urban-rural disparities in institutional delivery in Bangladesh: Assessing the effect of antenatal care dynamics.

Background: Improving access to institutional delivery is crucial for reducing maternal and newborn mortality. However, government efforts to enhance maternal healthcare in low- and middle-income countries (LMICs) like Bangladesh mostly contribute to a significant increase in antenatal care (ANC) uptake, while institutional delivery rates remains low, with notable urban-rural differences. We, therefore, explored the association of the place, timing, and quality of ANC with the uptake of institutional delivery services, as well as explored the urban-rural differences in these associations. Methods: The study analysed data of 3,549 mothers, extracted from the 2022 Bangladesh Demographic and Health Survey (BDHS). The outcome variable was the utilisation of institutional delivery (yes, no). The timing, location and quality of ANC were considered as the key exposure variables. A multilevel mixed-effects Poisson regression model was employed to explore associations between the outcome and the exposures. Additionally, an urban-rural differential analysis was conducted to assess the urban-rural differences in the association between exposure and outcome variables. Results: We observed a noticeable difference in institutional delivery rates between urban (76.3%) and rural areas (60.5%), with an overall rate of 64.7%. Women who accessed ANC in the 2nd or 3rd trimester were less likely to have an institutional delivery (aPR: 0.92 and 0.74) compared to those who initiated ANC in the 1st trimester. Receiving ANC at home significantly decreased the likelihood of institutional delivery (aPR: 0.74), while ANC from private or public facilities showed no significant association. Additionally, having at least one ANC visit from a medically trained provider (MTP) significantly increased the likelihood of institutional delivery (aPR: 1.83). Receiving quality ANC services also found increasing the likelihood of institutional delivery (aPR: 1.21), with these effects being more pronounced among rural women. The urban-rural differential analysis revealed no significant variation in the determinants of institutional delivery, except for the timing of ANC initiation. Conclusion: Urban-rural differences in institutional delivery rates are evident, with early ANC initiation, home-based ANC, and visits with MTPs being associated with higher institutional delivery rates. Initiation of ANC was the only determinant showing significant urban-rural variation, with notable differences in effect size for all other determinants. Therefore, to increase institutional delivery rates, particularly in rural areas, focusing on early initiation of ANC visits is important. In addition, improving the access to quality ANC services in the rural healthcare facilities is particularly crucial to increase the institutional delivery rates.