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Women’s enlightenment and early antenatal care initiation are determining factors for the use of eight or more antenatal visits in Benin: further analysis of the Demographic and Health Survey

Women’s enlightenment and early antenatal care initiation are determining factors for the use of... Background: Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for vital health care functions, such as disease prevention, health promotion, screening, and diagnosis. It has been widely confirmed that by implementing appropriate evidence-based practices, ANC can save lives. Previous studies investigated the utilization of ANC based on the four visits model. The new guidelines set by the World Health Organization 2016 recommended increasing contacts with health providers from four to eight contacts. The present study aims to determine the frequency, determinants, and socioeconomic inequalities of ANC utilization based on the eight or more contacts in Benin. This will provide information for policy makers to improve ANC utilization. Methods: We used a population-based cross-sectional data from Benin Demographic and Health Survey (BDHS)— 2017–2018. The outcome variable considered for this study was coverage of ≥ 8 ANC contacts. About 1094 women of reproductive age who became pregnant after the new guideline of ≥ 8 ANC contacts was endorsed were included in this study. The determinants for ≥ 8 ANC contacts were measured using multivariable logistic regression. Concentration (Conc.) Index and Lorenz curves were used to estimate the socioeconomic inequalities of ≥ 8ANC contacts. The level of significance was set at P <0.05. Results: The coverage of ≥ 8 ANC contacts was 8.0%; 95%CI 6.5%, 9.7%. The results of timing of antenatal care initiation showed that women who had late booking (after 1st trimester) had 97% reduction in ≥ 8 ANC contacts compared with women who initiated ANC contacts within the first trimester (adjusted odds ratio (AOR) = 0.03; 95% CI 0.00, 0.21). In addition, women with medium or high enlightenment were 4.55 and 5.49 as more likely to have ≥ 8 ANC contacts, compared with women having low enlightenment (AOR = 4.55; 95% CI 1.41, 14.69 and AOR = 5.49; 95% CI 1.77, 17.00, respectively). Conc. Index for the household wealth-related factor was 0.33; p < 0.001 for urban women and 0.37; p < 0.001 for the total sample. Similarly, Conc. Index for maternal education was 0.18; p =0.006 forurban women and 0.21; p < 0.001 for the total sample. (Continued on next page) * Correspondence: mic42006@gmail.com Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 2 of 12 (Continued from previous page) Conclusion: Secondary analysis of the BDHS showed low coverage of ≥ 8 ANC contacts in Benin. In addition, women’s enlightenment, early ANC initiation, and socioeconomic inequalities determined the coverage of ≥ 8 ANC contacts. The findings bring to limelight the need to enhance women’s enlightenment through formal education, exposure to mass media, and other channels of behavior change communication. Health care programs which encourage early antenatal care initiation should be designed or strengthened to enhance the coverage of ANC contacts in Benin. Keywords: ANC, Sub-Saharan Africa, Benin, Maternal health, Women 1 Introduction increase in the number of ANC contacts seems to be as- Globally, pregnancy-related complications contribute to sociated with an increase in maternal satisfaction and over 50% of deaths among women yearly. According to well-being compared with fewer ANC contacts [7]. the World Health Organization (WHO), approximately Numerous factors influence the uptake of optimal 90–95% of these mortalities come from resource-poor ANC contacts. Empirical studies have shown that mater- countries [1]. In 2016, it was reported that the propor- nal age [4], educational level [8], planned pregnancies tion of maternal mortality ratio between resource- [9], and timing of first ANC visit [10] are factors associ- constrained settings and developed world was 239 and ated with adequate ANC visits. In addition, exposure to 12 per 100,000 live births respectively [2]. The staggering mass media, family income, and accessibility of the ob- reports of maternal deaths in resource-constrained set- stetric service are also associated with increased tings have drawn global attention for urgent interven- utilization of antenatal care [9, 11, 12]. tion, as most of the deaths could be prevented through Benin, like several sub-Saharan Africa (SSA) countries, skilled birth attendance and increased ANC contacts. In- has an unfair share of adverse maternal health outcomes, creased ANC contacts are recommended to reduce ma- including pregnancy-related complications and deaths. ternal deaths by up to 8 per 1000 live births [3]. It can Worst still, the majority of maternal health indicators facilitate the uptake of preventive measures, timely de- such as ANC visits, institutional delivery, post-natal care, tection of danger signs, reduction in complications, and and contraceptive use have not improved beyond several address health care inequalities including those in re- SSA countries [13]. However, no study so far could be mote and marginalized settings [4]. traced that examined the coverage and factors associated In light of the above, WHO in 2016 unveiled a new with the new WHO ANC guideline of minimum 8 ANC antenatal care model by increasing contacts with health contacts in Benin. This study is conducted to explore providers throughout the pregnancy period from four to the coverage, determinants, and the socioeconomic in- eight contacts [3]. The guideline is targeted to respond equalities of ANC utilization based on the eight or to the complex nature of the challenges surrounding the more ANC contacts in Benin. practice and delivery of ANC within the health systems, and to prioritize woman-centered care and well-being 2 Materials and methods and not to prevent deaths and complications only. Evi- 2.1 Data source dence showed that a higher frequency of ANC contacts We utilized a population-based cross-sectional data from with the health care providers could lead to a significant Benin Demographic and Health surveys (BDHS). BDHS reduction in adverse health conditions [3, 4]. The in- 2017-18 is the fifth of its kind. About 1094 women of re- creased opportunities to detect and manage potential productive age who became pregnant after the new problems could enhance services such as counseling on guideline of ≥ 8 ANC contacts was endorsed were in- healthy diet, optimal nutrition, blood tests, uptake of cluded in this study. The data is available in the public intermittent preventive treatment in pregnancy, and tet- domain and accessed at http://dhsprogram.com/data/ anus vaccination [3]. available-datasets.cfm. Evidence-based data has pointed that the focused ante- natal care (FANC) model developed in the 1990s was 2.2 Study design linked with persistent perinatal and maternal deaths [5]. BDHS used a stratified multi-stage cluster random sam- Meanwhile, an analysis of the WHO ANC trial showed pling technique, and data was collected on vital reproduct- that persistence in perinatal mortality was more likely to ive health issues via structured interviewer-administered be due to increased stillbirths [6]. The contacts during questionnaires. BDHS used nationally representative data the third trimester are at critical time points that may to collect information on demographic, health, and nutri- allow assessment of well-being and interventions to re- tion indicators. The survey is funded by the United States duce stillbirths. Moreover, evidence suggests that an Agency for International Development (USAID). BDHS Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 3 of 12 2017-18 utilized households as the sampling unit. Within to poorest/poorer/middle/richer/richest categories [19, each sample household, all eligible women were inter- 20]. Furthermore, neighborhood socioeconomic disad- viewed. Details of DHS data collection procedure have vantaged level used items such as rural residence, poor- been reported previously [14]. est household wealth level, no formal education, and not working. Using PCA, the standardized z-score was used 2.3 Study settings to disentangle the overall assigned scores to low, Benin has twelve geographical regions: Alibori, Atacora, medium, and high. Atlantique, Borgou, Collines, Couffo, Donga, Littoral, Women’s enlightenment was measured from a list of Mono, Quémé, Plateau, and Zou. The country spans data elements (education, read newspaper/magazines, from north to south and a long stretched country in listen to radio, and watch television), and decision- West Africa, located west of Nigeria and east of Togo. It making power was measured from a list of data elements is bordered to the north by Niger and Burkina Faso, in (respondent involvement in the decision on how to south by the Bight of Benin, in the Gulf of Guinea, that spend her earnings, decision on her health care, decision part of the tropical North Atlantic Ocean which is on large household purchases, decision on visits to fam- roughly south of West Africa. Benin’s former name, until ily or relatives, decision on what to do with money hus- 1975, was Dahomey. Benin has a population of 11.48 band/partner earns). Using PCA, the factors were million people (in 2018) [15], and Porto-Novo, a port on distilled into a more generalized set of weights that score an inlet of the Gulf of Guinea, is the nation’s capital city. “women’s enlightenment” and “decision making power” The largest city and economic capital is Cotonou. Spoken between 0 and 100. The standardized z-scores were used languages are French (official), Fon, and Yoruba [16]. to disentangle the overall assigned scores to low, medium, and high. 2.4 Selection criteria In addition, the following factors were examined: mater- We included women who became pregnant after the nal age 15–19/20–24/25–29/30–34/35–39/40–44/45–49; guideline of ≥ 8 ANC contacts has been endorsed by age at first marriage (years): < 18/18–24/>24; family type: WHO [3]. In the guideline, ANC models with a mini- monogyny/polygyny; timing to ANC contact initiation: mum of eight contacts are recommended to reduce peri- early booking (within 1st trimester)/late booking (after 1st natal mortality and improve women’s experience of care. trimester); number of children ever born: 1–3/> 3; birth The 2016 WHO ANC model replaced the previous four- order: 1st/2nd/3rd/4th/> 4th; preceding birth interval: first visit FANC model. Accordingly, any woman who could birth/< 24 months/24–36 months/> 36 months; religion: not recall the approximate number of ANC contacts was Christianity/Islam/Traditional and others; sex of household excluded from the study. head: male/female; ever had a terminated pregnancy: yes/ no; health insurance coverage: not covered/covered; marital 2.5 Outcome variable status: not married/currently married or living with a part- ANC was measured dichotomously: < 8 ANC contacts ner/formerly married; wanted pregnancy when became vs. ≥ 8 ANC contacts. The WHO ANC guideline recom- pregnant: then/later/no more; maternal education: no for- mendations mapped to the eight recommended contacts mal education/primary/secondary/tertiary; and place of and present a summary framework for the 2016 WHO residence: urban/rural. These factors were included based ANC model in support of a positive pregnancy experi- on previous studies which examined the factors associated ence [3, 17, 18]. with maternal health care services [13, 21]. 2.6 Explanatory variables 2.7 Ethical consideration Household wealth quintile: principal component analysis This study was based on an analysis of population-based (PCA) was used to assign the wealth indicator weights. dataset available in public domain/online with all identi- This procedure assigned scores and standardized the fier information removed. The authors communicated wealth indicator variables such as bicycle, motorcycle/ with MEASURE DHS/ICF International, and permission scooter, car/truck, main floor material, main wall mater- was granted to download and use the data. The DHS ial, main roof material, sanitation facilities, water source, project obtained the required ethical approvals from the radio, television, electricity, refrigerator, cooking fuel, relevant research ethics committee in Benin, West furniture, and number of persons per room. The factor Africa, before the survey was conducted to ensure that coefficient scores (factor loadings) and z-scores were cal- the protocols are in compliance with the U.S. Depart- culated. For each household, the indicator values were ment of Health and Human Services regulations for the multiplied by the loadings and summed to produce the protection of human subjects. Written informed con- household’s wealth index value. The standardized z- sents were obtained from participants before being re- score was used to disentangle the overall assigned scores cruited in the surveys. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 4 of 12 2.8 Statistical analysis mean of the indicator. This would impede cross-factor Women’s characteristics were presented using percent- comparisons because there are substantial differences in ages. The collinearity testing approach adopted the cor- means between locations. To address this issue, we used relation method to estimate interdependence between an alternative but related index introduced by Erreygers variables. A cutoff of 0.7 was used to examine the multi- [24]. Statistical significance was determined at p < 0.05. collinearity known to cause major concerns [22]. Birth Data analysis was conducted using Stata Version 14 (Sta- interval was retained in the logistic model as it was taCorp., College Station, TX, USA). found to have strong association with birth order. Other significant variables from the bivariate analysis were 3 Results retained in the model due to lack of multicollinearity. 3.1 Characteristics of women The Survey (“svy”) module was used to adjust for strati- In total, 1094 women who became pregnant after the fication, clustering, and sampling weights to compute policy of ≥ 8 ANC contacts was endorsed were included the estimates of ≥ 8 ANC contacts across the study vari- in the study. The coverage of ≥ 8 ANC contacts was ables. Chi-square test was used to examine the associ- 8.0%; 95% CI 6.5%, 9.7%. Women between 25–29 years ation between ≥ 8 ANC contacts and the explanatory (9.5%) and 30–34 years (10.8%) accounted for the high- variables. All significant variables from the bivariate ana- est coverage of ≥ 8 ANC contacts. Women from low lysis were included in the multivariable logistic regres- neighborhood socioeconomic disadvantaged group re- sion model to calculate the adjusted odds ratios (with ported the highest coverage of about 14.9% of ≥ 8ANC corresponding 95% CI). Based on the estimation of mul- contacts. In addition, women with low enlightenment tivariable logistic regression model, we predicted the (2.5%) and low decision-making power (5.2%) had the least coverage of ≥ 8 ANC contacts. Women who got probability of ≥ 8 ANC contacts. Thus, PrðY ¼ 1jSet½E married at age > 24 years, in monogynous marriage, ini- tiated ANC contacts within first trimester, had 1–3 chil- ¼ eÞ ¼ p ^ PrðZ ¼ zÞ where Set[E = e] reflects put- ez dren, and 1st in birth order or Christians, had the ting all observations to a single exposure level e, and Z = highest coverage of ≥ 8 ANC contacts (13.9%, 9.2%, z refers to a given set of observed values for the covari- 14.9%, 9.3%, and 11.8% respectively). Those who had his- ate vector Z. Furthermore, p ^ is the predicted probabil- ez tory of terminated pregnancy (12.3%), covered by health ities of ≥ 8 ANC contacts for any E = e and Z = z. The insurance (44.4%), and not married (12.5%) had higher marginal effects indicate a weighted average over the dis- coverage of ≥ 8 ANC contacts in Benin. Several maternal tribution of the covariates and are equal to estimates got characteristics were significantly associated with ≥ 8 by standardizing to the entire population. As a post- ANC contacts (P < 0.05) at the bivariate analysis are pre- logistic regression test, the exposure E is set to the level sented in Table 1. e for all women in the dataset, and the logistic regression coefficients are used to compute predicted probabilities 3.2 Factors associated with ≥ 8 ANC contacts for every woman at their observed covariate pattern and (multivariable logistic regression) newly exposure value. Because predicted probabilities The results of timing to antenatal care initiation showed are computed under the same distribution of Z, there is that women who had late booking (after 1st trimester) no covariate of the corresponding effect measure esti- had 97% reduction in ≥ 8 ANC contacts compared with mates [23]. women who initiated ANC contacts within the first tri- Furthermore, Lorenz curves were used to present so- mester (AOR = 0.03; 95% CI 0.00, 0.21). In addition, cioeconomic inequalities as a plot of cumulative propor- women with medium or high enlightenment were 4.55 tion of ≥ 8 ANC contacts among women against and 5.49 times as likely to have ≥ 8 ANC contacts, com- cumulative proportion of the population ordered by pared with women having low enlightenment (AOR = household wealth quintiles and maternal education. 4.55; 95% CI 1.41, 14.69 and AOR = 5.49; 95% CI 1.77, Concentration Index (CI) is positive when the Lorenz 17.00) Table 2. curve is below the line of equality indicating the concen- tration of ≥ 8 ANC contacts concentrates among high 3.3 Marginal effects of the factors associated with ≥ 8 socioeconomic groups and vice versa. The urban vs. ANC contacts rural place of residence was used for stratified analyses. In Table 3, marginal effect analysis was conducted to de- In the Lorenz curves, women were ranked according to cipher the effects of the factors associated with ≥ 8ANC ascending household wealth-related status to estimate contacts. From the predictive marginal effects results, as- their position in the cumulative distribution of socioeco- suming the distribution of all factors remained the same nomic status. Conventionally, when it is applied to bin- among women, but every woman had low neighborhood ary indicators, the concentration index depends on the socioeconomic disadvantaged status, we would expect Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 5 of 12 Table 1 Characteristics of women attending ≥ 8 ANC contacts in Benin, West Africa, BDHS 2017–18 Variable ≥ 8 ANC visits Total P value No (92.0%) Yes (8.0%) Maternal age 15–19 116 (95.9) 5 (4.1) 121 0.219 20–24 260 (92.9) 20 (7.1) 280 25–29 284 (90.5) 30 (9.5) 314 30–34 181 (89.2) 22 (10.8) 203 35–39 111 (93.3) 8 (6.7) 119 40–44 38 (95.0) 2 (5.0) 40 45–49 17 (100.0) 0 (0.0) 17 Neighborhood socioeconomic disadvantaged status Tertile 1 (least disadvantaged) 309 (85.1) 54 (14.9) 363 < 0.001* Tertile 2 342 (93.4) 24 (6.6) 366 Tertile 3 (most disadvantaged) 356 (97.5) 9 (2.5) 365 Women’s enlightenment level Low 422 (97.5) 11 (2.5) 433 < 0.001* Medium 291 (91.2) 28 (8.8) 319 High 315 (92.1) 27 (7.9) 342 Decision-making power Low 273 (94.8) 15 (5.2) 288 0.022* Medium 213 (89.1) 26 (10.9) 239 High 85 (87.6) 12 (12.4) 97 Age at first marriage (years) < 18 377 (94.3) 23 (5.7) 400 0.029* 18–24 521 (91.7) 47 (8.3) 568 > 24 74 (86.1) 12 (13.9) 86 Family type Monogyny 624 (90.8) 63 (9.2) 687 0.017* Polygyny 326 (95.0) 17 (5.0) 343 Timing of ANC initiation Early booking (within 1st trimester) 441 (85.1) 77 (14.9) 518 < 0.001* Late booking (after 1st trimester) 440 (99.5) 2 (0.5) 442 Number of children ever born 1–3 565 (90.7) 58 (9.3) 623 0.056 > 3 442 (93.8) 29 (6.2) 471 Birth order 1st 210 (88.2) 28 (11.8) 238 0.042* 2nd 174 (92.1) 15 (7.9) 189 3rd 181 (92.3) 15 (7.7) 196 4th 149 (90.8) 15 (9.2) 164 > 4th 293 (95.4) 14 (4.6) 307 Preceding birth interval First birth 212 (87.6) 30 (12.4) 242 0.002* < 24 months 114 (99.1) 1 (0.9) 115 24–36 months 337 (92.3) 28 (7.7) 365 Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 6 of 12 Table 1 Characteristics of women attending ≥ 8 ANC contacts in Benin, West Africa, BDHS 2017–18 (Continued) Variable ≥ 8 ANC visits Total P value No (92.0%) Yes (8.0%) > 36 months 344 (92.5) 28 (7.5) 372 Religion Christianity 457 (88.2) 61 (11.8) 518 < 0.001* Islam 383 (96.7) 13 (3.3) 396 Traditional and others 167 (92.8) 13 (7.2) 180 Sex of head of household Male 856 (92.2) 72 (7.8) 928 0.575 Female 151 (91.0) 15 (9.0) 166 Ever had a terminated pregnancy Yes 93 (87.7) 13 (12.3) 106 0.084 No 914 (92.5) 74 (7.5) 988 Health insurance coverage Not covered 1001 (92.3) 84 (7.7) 1085 < 0.001* Covered 5 (55.6) 4 (44.4) 9 Marital status Not married 35 (87.5) 5 (12.5) 40 0.523 Currently married/living with a partner 955 (92.2) 81 (7.8) 1036 Formerly married 17 (94.4) 1 (5.6) 18 Currently residing with husband/partner Living together 812 (92.2) 69 (7.8) 881 0.969 Staying elsewhere 143 (92.3) 12 (7.7) 155 Wanted pregnancy when became pregnant Then 731 (92.1) 63 (7.9) 794 0.992 Later 210 (92.1) 18 (7.9) 228 No more 66 (91.7) 6 (8.3) 72 *Significant at p < 0.05 11% of ≥ 8 ANC contacts. If every woman had high ma- ternal enlightenment or high decision-making power, we would expect 11% and 8% of ≥ 8 ANC contacts. If in- Table 2 Logistic regression of the factors associated with ≥ 8 stead the distribution of neighborhood socioeconomic ANC contacts among women of reproductive age in Benin, disadvantaged status, maternal enlightenment, and West Africa, BDHS 2017–2018 decision-making power were as observed and other co- Variable AOR 95% CI P variates remained the same among women, but no Timing to ANC contacts initiation woman had first marriage before age 25 years or had Early booking (within 1st trimester) 1.00 monogynous family life, we would expect about 10% and 9% of ≥ 8 ANC contacts respectively. Furthermore, if in- Late booking (after 1st trimester) 0.03 0.00–0.21 0.001* stead the spread of the aforementioned variables were as Women’s enlightenment level observed and other covariates remained equal among Low 1.00 women, but every woman initiated ANC contacts within Medium 4.55 1.41–14.69 0.011* 1st trimester were Christians or had health insurance High 5.49 1.77–17.00 0.003* coverage, we would expect 13%, 9%, and 16% of ≥ 8 Model adjusted for neighborhood socioeconomic disadvantaged level, ANC contacts respectively. In Table 3, we practically ob- decision-making power, age at 1st marriage, family type, preceding birth tained the predictive marginal effects of the factors asso- interval, religion, and health insurance coverage *Significant at p < 0.05 ciated with ≥ 8 ANC contacts. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 7 of 12 Table 3 Marginal effect of the factors associated with the frequency of ANC visits among women of reproductive age in Benin, West Africa, BDHS 2017–2018 Variable Marginal effect 95% CI P Neighborhood socioeconomic disadvantaged status Tertile 1 (least disadvantaged) 0.11 0.07–0.15 < 0.001* Tertile 2 0.07 0.04–0.11 < 0.001* Tertile 3 (most disadvantaged) 0.05 0.01–0.09 0.018* Maternal enlightenment level Low 0.03 0.00–0.05 0.039* Medium 0.10 0.05–0.14 < 0.001* High 0.11 0.07–0.15 < 0.001* Decision-making power Low 0.08 0.04–0.12 < 0.001* Medium 0.09 0.06–0.12 < 0.001* High 0.08 0.04–0.13 0.001* Age at first marriage (years) < 18 0.08 0.04–0.13 < 0.001* 18–24 0.08 0.05–0.11 < 0.001* > 24 0.10 0.04–0.17 0.002* Family type Monogyny 0.09 0.06–0.12 < 0.001* Polygyny 0.07 0.03–0.11 < 0.001* Timing to ANC visits initiation Early booking (within 1st trimester) 0.13 0.10–0.17 < 0.001* Late booking (after 1st trimester) 0.01 − 0.01–0.02 0.315 Preceding birth interval First birth 0.10 0.04–0.16 0.001* < 24 months 0.02 − 0.02–0.05 0.310 24–36 months 0.09 0.05–0.12 < 0.001* > 36 months 0.10 0.06–0.13 < 0.001* Religion Christianity 0.09 0.07–0.12 < 0.001* Islam 0.06 0.02–0.10 0.004* Traditional and others 0.08 0.02–0.14 0.010* Health insurance coverage Not covered 0.08 0.06–0.10 < 0.001* Covered 0.16 0.02–0.30 0.029* *Significant at p < 0.05; McFadden’s R-squared for model fitness = 0.28 3.4 Socioeconomic inequalities (Lorenz curve and group and maternal education had higher ≥ 8ANC concentration index) contacts. Figures 1, 2, 3, 4 showed the household wealth-related In Table 4, we presented the coverage of ≥ 8ANC and maternal education inequalities for women of repro- contacts across household wealth quintile and maternal ductive age who had ≥ 8 ANC contacts in Benin, West education. Overall, the richest women and higher mater- Africa. The farther the Lorenz curves sags away from nal education had the highest coverage of ≥ 8 ANC con- the line of equality, the greater the degree of inequalities. tacts. Using Concentration Index, we quantified the The curves revealed that women from higher wealth degree of wealth-related and maternal education Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 8 of 12 Fig. 1 Urban-rural differential in household wealth-related inequalities of ≥ 8 ANC contacts inequalities in ≥ 8 ANC contacts. The outcome (≥ 8 ANC and whether the recommendation in the guideline has been contacts) was significantly more in the higher household implemented or influenced policy decisions. The recom- wealth groups and maternal education, specifically among mendation requires that the first ANC contact should take the urban women and total sample: Household wealth- place in the first 12 weeks of gestation (within first trimester related factor: urban women—Conc. Index = 0.33; p < of the pregnancy); thereafter, two other contacts are sched- 0.001; total sample—Conc. Index = 0.37; p <0.001. Mater- uled to take place during the 20th and 26th weeks of gesta- nal education: urban women—Conc. Index = 0.18; p = tion (that is, during the second trimester of the pregnancy), 0.006; total sample—Conc. Index = 0.21; p <0.001). and the remaining five contacts are scheduled to place dur- ing the third trimester (precisely at 30th, 34th, 36th, 38th, and 40th weeks of gestation) [25]. 4 Discussion The results of this study revealed that after about 3 About 3 years (since November 2016) after the publication years of the launch of WHO minimum of 8 ANC con- and dissemination of ≥ 8 ANC contacts guideline, this sur- tacts model, less than one tenth (only 8.0%) of women in vey is the foremost to select respondents and gauges the Benin had at least 8 ANC contacts with the health care status and extent of in-country utilization and adaptation, Fig. 2 Urban-rural differential in maternal education inequalities of ≥ 8 ANC contacts Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 9 of 12 Fig. 3 Overall household wealth-related inequalities of ≥ 8 ANC contacts providers throughout the period of their pregnancy. In a In the marginal effects model, women from the least previous study, which examined the coverage of mini- socioeconomic disadvantaged neighborhood were found mum 4 ANC visits in Benin, the findings from 2006 and to have had higher predictive value of ≥ 8 ANC contacts. 2012 data showed the coverage were about 61.0% and This can be viewed in the light that women who live in higher than the current minimum of 8 ANC contacts an economic advantaged neighborhood may be well-off, [13]. This result clearly showed that the new WHO 8 more enlightened, and have more access to health facil- ANC contacts model is yet to be institutionalized or ac- ity than those living in economically disadvantaged cepted among women of childbearing age in Benin Re- neighborhood. The pro-rich neighborhood is commonly public. It is most likely that supply-side and demand- where the members of richest wealth quintile, educated, side factors could be responsible for this low minimum and the affluent members of a given society dwell. These of 8 ANC contacts uptake. For example, lack of behavior areas are commonly equipped with the best of health change communication/awareness, poor health care sys- care, technology, and education compared with the poor tem, or lack of buy-in by stakeholders in health system or socioeconomically most disadvantaged areas. This including the providers can be linked to this staggering phenomenon abounds in most parts of SSA countries. outcome. The reason for the inability to have maximum ANC Fig. 4 Overall maternal education inequalities of ≥ 8 ANC contacts Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 10 of 12 Table 4 Prevalence and Concentration Index of ≥ 8 ANC wealth status had greater uptake of ANC contacts as rec- contacts by household wealth quintile and maternal education, ommended in the new guideline. BDHS, 2017-18 The enlightenment level of pregnant women was also Variable Urban Rural Total found to be correlated with ≥ 8 ANC contacts. Improved Household wealth quintile (%) enlightenment levels usually result from exposure to educational materials, listening to news, watching televi- Poorest 1.5 5.6 4.4 sion, reading newspapers, and passing through a formal Poorer 6.8 2.1 3.0 education. This may be related to the knowledge of the Middle 12.5 4.1 6.2 importance of registering for ANC and also completing Richer 5.1 4.4 4.7 at least 8 ANC contacts. These factors have previously Richest 22.7 20.0 22.2 been reported to positively influence optimal utilization Overall 12.9 4.9 8.0 of ANC among women in Benin [30] and in rural Malawi [31]. Moreover, we observed that high decision- Concentration Index 0.33 0.16 0.37 making power is a factor that increased at least 8 ANC SE 0.07 0.10 0.06 contacts. This factor could result from increased auton- P value < 0.001* 0.087 < 0.001* omy for the women, more access to health information, Urban-rural comparison and an enhanced economic and monetary status [12]. z-stat − 1.46 Therefore, it is important that the girl child should be CI difference − 0.17 educated up to post-secondary school level and empow- ered for greater independence such that the issues con- P value 0.143 cerning her health needs especially the reproductive Maternal education (%) aspect will be decisively taken by her. In addition, more No education 9.1 3.7 5.5 communication through using mass media providing in- Primary 16.5 8.9 11.9 formation about the importance of this new ANC model Secondary 14.2 3.3 9.1 would be helpful in facilitating behavior change [32]. The Tertiary 50.0 40.0 47.1 multivariable logit model shows that women who were highly or moderately enlightened were more likely to have Overall 12.9 4.9 8.0 8 or more antenatal care contacts. Education or enlighten- Concentration Index 0.18 0.15 0.21 ment has been reported to be a protective factor that en- SE 0.07 0.08 0.05 hances women’s utilization of health care services as well P value 0.006* 0.067 < 0.001* as reproductive health decision-making [33, 34]. Urban-rural comparison Women who married after age 24 years had higher z-stat − 0.34 predictive values of at least 8 ANC contacts. This finding is in agreement with the report of a previous study CI difference − 0.03 β where the majority of the pregnant women who had P value 0.734 good utilization of ANC contacts had their marriage α β P value and P value were obtained using the Concentration Index for overall after adolescent age [35]. The explanations could be that inequalities across socioeconomic groups and measuring rural vs. urban differences respectively the delay of timing to marriage may be due to spending SE standard error more time in educational institution or career develop- *Significant at p < 0.05 ment [36], which is a measure of improving women’s empowerment. These folks could have better knowledge contacts has over the years been linked to financial con- of the benefits of optimal ANC contacts during preg- straints, poor access to health facility, lack of decision- nancy which is in line with reports from previous studies making power as regard to reproductive health matters, [35, 37]. Education is one of the major ways to empower proximity to health facility, and so forth [12, 26–28]. women. It provides them with higher assurance and These factors that are linked to low frequency of ANC competence to make decisions in the use of available contacts should be of great concern to policy makers modern health care services for themselves and their and funding agencies. Some studies have acknowledged children [33]. lack of knowledge of the importance of ANC contacts, In addition, women who initiated ANC early or at the ignorance of the time to start ANC contacts, as reasons first trimester of pregnancy had higher predictive value for underutilization of ANC in general [12, 27, 29]. This of ≥ 8 ANC contacts. Also, in the logit model, it was finding corroborates with the present results from the found that late booking for ANC had large reduction in analysis of socioeconomic inequalities, where the edu- the odds of having at least 8 ANC contacts during preg- cated women and those from households with high nancy. Similarly, the findings from previous studies Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 11 of 12 showed that early booking for ANC would result in opti- age to improve their understanding of the importance of mal number of ANC contacts during pregnancy [38]. the new model of care. Enlightening women and provid- Furthermore, women who had health insurance cover- ing support for early initiation of ANC contacts and in- age, monogynous family, long preceding birth interval or creasing equity-focused efforts will also help to improve first childbirth, and of Christian religious belief had in- the uptake of the minimum 8 ANC contacts. creased predictive values to the uptake of a minimum of Abbreviations 8 ANC contacts. ANC: Antenatal care; FANC: Focused antenatal care; MDGs: Millennium The findings from the socioeconomic inequalities of ≥ Development Goals; SDGs: Sustainable Development Goals; SSA: Sub-Saharan Africa; UN: United Nations; WHO: World Health Organization 8 ANC contacts revealed that women from non-poor households and the educated women had higher uptake Acknowledgements of ≥ 8 ANC contacts, especially in the urban residence. The authors appreciate the MEASURE DHS project for the approval and This is similar to previous results obtained for the access to the original data. utilization of maternal health care services in Benin [13]. Authors’ contributions The SDG-3 is known to support reduction in inequal- ME conceived and designed the study, performed data analysis, and wrote ities and ensure health for all populations. Therefore, be- the results. AB, CIN, and AO review the literature, wrote the discussion of the findings, and critically reviewed the manuscript for its intellectual content. All yond the utilization of ≥ 8 ANC to reach the most authors read and approved the final version of the manuscript. disadvantaged group of women, the uptake of maternal care services must be considered to achieve the set goals. Funding This research received no grant from any funding agency in the public, Strengthening health care programs and policies can en- commercial, or not-for-profit sectors. hance optimal ANC contacts uptake among women of reproductive age, as well as improve the utilization of Availability of data and materials maternal care services, particularly for the uneducated, Data for this study were sourced from Demographic and Health surveys (DHS) and available here: http://dhsprogram.com/data/available-datasets.cfm. low household wealth quintiles, and those who live in hard-to-reach rural residence. Ethics approval and consent to participate Ethics approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and 4.1 Strengths and limitations ethical standards are available at http://dhsprogram.com/data/available- This is the foremost nationwide analyses that explore datasets.cfm. Consent to participate is not applicable. the uptake of at least 8 ANC contacts in Benin and as such could serve as a benchmark and stimulus for fur- Consent for publication Demographic and Health Survey is a de-identified open-source dataset. ther nationwide studies on related subject matter. An- Therefore, the requirement of consent for publication is not applicable. other strength is the use of current nationally representative datasets which makes the findings of the Competing interests The authors declare that the research was conducted in the absence of any study generalizable to women of reproductive age in commercial or financial relationships that could be construed as a potential Benin. However, this analysis has some drawbacks. conflict of interest. Prominently, the analyses utilized cross-sectional data; Author details hence, only associations and no causal relationships Department of Epidemiology and Medical Statistics, Faculty of Public Health, could be established. Moreover, our inability to measure College of Medicine, University of Ibadan, Ibadan, Nigeria. Center of sources of demand-side unobserved heterogeneity across Excellence in Reproductive Health Innovation (CERHI), College of Medical Sciences, University of Benin, Benin City, Nigeria. Department of Public & the secondary data might have biased our estimates. The Environmental Health, School of Medicine & Allied Health Sciences, unavailability of relevant variables other than those col- University of The Gambia, Serekunda, Gambia. Project Management Unit, lected was a major limitation in the DHS data. Further- Management Sciences for Health, Abuja, Nigeria. more, recall bias could have occurred due to the self- Received: 30 August 2019 Accepted: 30 April 2020 reported number of ANC contacts. 5 Conclusion References 1. World Health Organization. Make every mother and child count. The world Analysis of the BDHS showed low coverage of ≥ 8ANC health report. 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J Health Econ. 2009;28(2): 504–15. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Women’s enlightenment and early antenatal care initiation are determining factors for the use of eight or more antenatal visits in Benin: further analysis of the Demographic and Health Survey

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Abstract

Background: Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for vital health care functions, such as disease prevention, health promotion, screening, and diagnosis. It has been widely confirmed that by implementing appropriate evidence-based practices, ANC can save lives. Previous studies investigated the utilization of ANC based on the four visits model. The new guidelines set by the World Health Organization 2016 recommended increasing contacts with health providers from four to eight contacts. The present study aims to determine the frequency, determinants, and socioeconomic inequalities of ANC utilization based on the eight or more contacts in Benin. This will provide information for policy makers to improve ANC utilization. Methods: We used a population-based cross-sectional data from Benin Demographic and Health Survey (BDHS)— 2017–2018. The outcome variable considered for this study was coverage of ≥ 8 ANC contacts. About 1094 women of reproductive age who became pregnant after the new guideline of ≥ 8 ANC contacts was endorsed were included in this study. The determinants for ≥ 8 ANC contacts were measured using multivariable logistic regression. Concentration (Conc.) Index and Lorenz curves were used to estimate the socioeconomic inequalities of ≥ 8ANC contacts. The level of significance was set at P <0.05. Results: The coverage of ≥ 8 ANC contacts was 8.0%; 95%CI 6.5%, 9.7%. The results of timing of antenatal care initiation showed that women who had late booking (after 1st trimester) had 97% reduction in ≥ 8 ANC contacts compared with women who initiated ANC contacts within the first trimester (adjusted odds ratio (AOR) = 0.03; 95% CI 0.00, 0.21). In addition, women with medium or high enlightenment were 4.55 and 5.49 as more likely to have ≥ 8 ANC contacts, compared with women having low enlightenment (AOR = 4.55; 95% CI 1.41, 14.69 and AOR = 5.49; 95% CI 1.77, 17.00, respectively). Conc. Index for the household wealth-related factor was 0.33; p < 0.001 for urban women and 0.37; p < 0.001 for the total sample. Similarly, Conc. Index for maternal education was 0.18; p =0.006 forurban women and 0.21; p < 0.001 for the total sample. (Continued on next page) * Correspondence: mic42006@gmail.com Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 2 of 12 (Continued from previous page) Conclusion: Secondary analysis of the BDHS showed low coverage of ≥ 8 ANC contacts in Benin. In addition, women’s enlightenment, early ANC initiation, and socioeconomic inequalities determined the coverage of ≥ 8 ANC contacts. The findings bring to limelight the need to enhance women’s enlightenment through formal education, exposure to mass media, and other channels of behavior change communication. Health care programs which encourage early antenatal care initiation should be designed or strengthened to enhance the coverage of ANC contacts in Benin. Keywords: ANC, Sub-Saharan Africa, Benin, Maternal health, Women 1 Introduction increase in the number of ANC contacts seems to be as- Globally, pregnancy-related complications contribute to sociated with an increase in maternal satisfaction and over 50% of deaths among women yearly. According to well-being compared with fewer ANC contacts [7]. the World Health Organization (WHO), approximately Numerous factors influence the uptake of optimal 90–95% of these mortalities come from resource-poor ANC contacts. Empirical studies have shown that mater- countries [1]. In 2016, it was reported that the propor- nal age [4], educational level [8], planned pregnancies tion of maternal mortality ratio between resource- [9], and timing of first ANC visit [10] are factors associ- constrained settings and developed world was 239 and ated with adequate ANC visits. In addition, exposure to 12 per 100,000 live births respectively [2]. The staggering mass media, family income, and accessibility of the ob- reports of maternal deaths in resource-constrained set- stetric service are also associated with increased tings have drawn global attention for urgent interven- utilization of antenatal care [9, 11, 12]. tion, as most of the deaths could be prevented through Benin, like several sub-Saharan Africa (SSA) countries, skilled birth attendance and increased ANC contacts. In- has an unfair share of adverse maternal health outcomes, creased ANC contacts are recommended to reduce ma- including pregnancy-related complications and deaths. ternal deaths by up to 8 per 1000 live births [3]. It can Worst still, the majority of maternal health indicators facilitate the uptake of preventive measures, timely de- such as ANC visits, institutional delivery, post-natal care, tection of danger signs, reduction in complications, and and contraceptive use have not improved beyond several address health care inequalities including those in re- SSA countries [13]. However, no study so far could be mote and marginalized settings [4]. traced that examined the coverage and factors associated In light of the above, WHO in 2016 unveiled a new with the new WHO ANC guideline of minimum 8 ANC antenatal care model by increasing contacts with health contacts in Benin. This study is conducted to explore providers throughout the pregnancy period from four to the coverage, determinants, and the socioeconomic in- eight contacts [3]. The guideline is targeted to respond equalities of ANC utilization based on the eight or to the complex nature of the challenges surrounding the more ANC contacts in Benin. practice and delivery of ANC within the health systems, and to prioritize woman-centered care and well-being 2 Materials and methods and not to prevent deaths and complications only. Evi- 2.1 Data source dence showed that a higher frequency of ANC contacts We utilized a population-based cross-sectional data from with the health care providers could lead to a significant Benin Demographic and Health surveys (BDHS). BDHS reduction in adverse health conditions [3, 4]. The in- 2017-18 is the fifth of its kind. About 1094 women of re- creased opportunities to detect and manage potential productive age who became pregnant after the new problems could enhance services such as counseling on guideline of ≥ 8 ANC contacts was endorsed were in- healthy diet, optimal nutrition, blood tests, uptake of cluded in this study. The data is available in the public intermittent preventive treatment in pregnancy, and tet- domain and accessed at http://dhsprogram.com/data/ anus vaccination [3]. available-datasets.cfm. Evidence-based data has pointed that the focused ante- natal care (FANC) model developed in the 1990s was 2.2 Study design linked with persistent perinatal and maternal deaths [5]. BDHS used a stratified multi-stage cluster random sam- Meanwhile, an analysis of the WHO ANC trial showed pling technique, and data was collected on vital reproduct- that persistence in perinatal mortality was more likely to ive health issues via structured interviewer-administered be due to increased stillbirths [6]. The contacts during questionnaires. BDHS used nationally representative data the third trimester are at critical time points that may to collect information on demographic, health, and nutri- allow assessment of well-being and interventions to re- tion indicators. The survey is funded by the United States duce stillbirths. Moreover, evidence suggests that an Agency for International Development (USAID). BDHS Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 3 of 12 2017-18 utilized households as the sampling unit. Within to poorest/poorer/middle/richer/richest categories [19, each sample household, all eligible women were inter- 20]. Furthermore, neighborhood socioeconomic disad- viewed. Details of DHS data collection procedure have vantaged level used items such as rural residence, poor- been reported previously [14]. est household wealth level, no formal education, and not working. Using PCA, the standardized z-score was used 2.3 Study settings to disentangle the overall assigned scores to low, Benin has twelve geographical regions: Alibori, Atacora, medium, and high. Atlantique, Borgou, Collines, Couffo, Donga, Littoral, Women’s enlightenment was measured from a list of Mono, Quémé, Plateau, and Zou. The country spans data elements (education, read newspaper/magazines, from north to south and a long stretched country in listen to radio, and watch television), and decision- West Africa, located west of Nigeria and east of Togo. It making power was measured from a list of data elements is bordered to the north by Niger and Burkina Faso, in (respondent involvement in the decision on how to south by the Bight of Benin, in the Gulf of Guinea, that spend her earnings, decision on her health care, decision part of the tropical North Atlantic Ocean which is on large household purchases, decision on visits to fam- roughly south of West Africa. Benin’s former name, until ily or relatives, decision on what to do with money hus- 1975, was Dahomey. Benin has a population of 11.48 band/partner earns). Using PCA, the factors were million people (in 2018) [15], and Porto-Novo, a port on distilled into a more generalized set of weights that score an inlet of the Gulf of Guinea, is the nation’s capital city. “women’s enlightenment” and “decision making power” The largest city and economic capital is Cotonou. Spoken between 0 and 100. The standardized z-scores were used languages are French (official), Fon, and Yoruba [16]. to disentangle the overall assigned scores to low, medium, and high. 2.4 Selection criteria In addition, the following factors were examined: mater- We included women who became pregnant after the nal age 15–19/20–24/25–29/30–34/35–39/40–44/45–49; guideline of ≥ 8 ANC contacts has been endorsed by age at first marriage (years): < 18/18–24/>24; family type: WHO [3]. In the guideline, ANC models with a mini- monogyny/polygyny; timing to ANC contact initiation: mum of eight contacts are recommended to reduce peri- early booking (within 1st trimester)/late booking (after 1st natal mortality and improve women’s experience of care. trimester); number of children ever born: 1–3/> 3; birth The 2016 WHO ANC model replaced the previous four- order: 1st/2nd/3rd/4th/> 4th; preceding birth interval: first visit FANC model. Accordingly, any woman who could birth/< 24 months/24–36 months/> 36 months; religion: not recall the approximate number of ANC contacts was Christianity/Islam/Traditional and others; sex of household excluded from the study. head: male/female; ever had a terminated pregnancy: yes/ no; health insurance coverage: not covered/covered; marital 2.5 Outcome variable status: not married/currently married or living with a part- ANC was measured dichotomously: < 8 ANC contacts ner/formerly married; wanted pregnancy when became vs. ≥ 8 ANC contacts. The WHO ANC guideline recom- pregnant: then/later/no more; maternal education: no for- mendations mapped to the eight recommended contacts mal education/primary/secondary/tertiary; and place of and present a summary framework for the 2016 WHO residence: urban/rural. These factors were included based ANC model in support of a positive pregnancy experi- on previous studies which examined the factors associated ence [3, 17, 18]. with maternal health care services [13, 21]. 2.6 Explanatory variables 2.7 Ethical consideration Household wealth quintile: principal component analysis This study was based on an analysis of population-based (PCA) was used to assign the wealth indicator weights. dataset available in public domain/online with all identi- This procedure assigned scores and standardized the fier information removed. The authors communicated wealth indicator variables such as bicycle, motorcycle/ with MEASURE DHS/ICF International, and permission scooter, car/truck, main floor material, main wall mater- was granted to download and use the data. The DHS ial, main roof material, sanitation facilities, water source, project obtained the required ethical approvals from the radio, television, electricity, refrigerator, cooking fuel, relevant research ethics committee in Benin, West furniture, and number of persons per room. The factor Africa, before the survey was conducted to ensure that coefficient scores (factor loadings) and z-scores were cal- the protocols are in compliance with the U.S. Depart- culated. For each household, the indicator values were ment of Health and Human Services regulations for the multiplied by the loadings and summed to produce the protection of human subjects. Written informed con- household’s wealth index value. The standardized z- sents were obtained from participants before being re- score was used to disentangle the overall assigned scores cruited in the surveys. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 4 of 12 2.8 Statistical analysis mean of the indicator. This would impede cross-factor Women’s characteristics were presented using percent- comparisons because there are substantial differences in ages. The collinearity testing approach adopted the cor- means between locations. To address this issue, we used relation method to estimate interdependence between an alternative but related index introduced by Erreygers variables. A cutoff of 0.7 was used to examine the multi- [24]. Statistical significance was determined at p < 0.05. collinearity known to cause major concerns [22]. Birth Data analysis was conducted using Stata Version 14 (Sta- interval was retained in the logistic model as it was taCorp., College Station, TX, USA). found to have strong association with birth order. Other significant variables from the bivariate analysis were 3 Results retained in the model due to lack of multicollinearity. 3.1 Characteristics of women The Survey (“svy”) module was used to adjust for strati- In total, 1094 women who became pregnant after the fication, clustering, and sampling weights to compute policy of ≥ 8 ANC contacts was endorsed were included the estimates of ≥ 8 ANC contacts across the study vari- in the study. The coverage of ≥ 8 ANC contacts was ables. Chi-square test was used to examine the associ- 8.0%; 95% CI 6.5%, 9.7%. Women between 25–29 years ation between ≥ 8 ANC contacts and the explanatory (9.5%) and 30–34 years (10.8%) accounted for the high- variables. All significant variables from the bivariate ana- est coverage of ≥ 8 ANC contacts. Women from low lysis were included in the multivariable logistic regres- neighborhood socioeconomic disadvantaged group re- sion model to calculate the adjusted odds ratios (with ported the highest coverage of about 14.9% of ≥ 8ANC corresponding 95% CI). Based on the estimation of mul- contacts. In addition, women with low enlightenment tivariable logistic regression model, we predicted the (2.5%) and low decision-making power (5.2%) had the least coverage of ≥ 8 ANC contacts. Women who got probability of ≥ 8 ANC contacts. Thus, PrðY ¼ 1jSet½E married at age > 24 years, in monogynous marriage, ini- tiated ANC contacts within first trimester, had 1–3 chil- ¼ eÞ ¼ p ^ PrðZ ¼ zÞ where Set[E = e] reflects put- ez dren, and 1st in birth order or Christians, had the ting all observations to a single exposure level e, and Z = highest coverage of ≥ 8 ANC contacts (13.9%, 9.2%, z refers to a given set of observed values for the covari- 14.9%, 9.3%, and 11.8% respectively). Those who had his- ate vector Z. Furthermore, p ^ is the predicted probabil- ez tory of terminated pregnancy (12.3%), covered by health ities of ≥ 8 ANC contacts for any E = e and Z = z. The insurance (44.4%), and not married (12.5%) had higher marginal effects indicate a weighted average over the dis- coverage of ≥ 8 ANC contacts in Benin. Several maternal tribution of the covariates and are equal to estimates got characteristics were significantly associated with ≥ 8 by standardizing to the entire population. As a post- ANC contacts (P < 0.05) at the bivariate analysis are pre- logistic regression test, the exposure E is set to the level sented in Table 1. e for all women in the dataset, and the logistic regression coefficients are used to compute predicted probabilities 3.2 Factors associated with ≥ 8 ANC contacts for every woman at their observed covariate pattern and (multivariable logistic regression) newly exposure value. Because predicted probabilities The results of timing to antenatal care initiation showed are computed under the same distribution of Z, there is that women who had late booking (after 1st trimester) no covariate of the corresponding effect measure esti- had 97% reduction in ≥ 8 ANC contacts compared with mates [23]. women who initiated ANC contacts within the first tri- Furthermore, Lorenz curves were used to present so- mester (AOR = 0.03; 95% CI 0.00, 0.21). In addition, cioeconomic inequalities as a plot of cumulative propor- women with medium or high enlightenment were 4.55 tion of ≥ 8 ANC contacts among women against and 5.49 times as likely to have ≥ 8 ANC contacts, com- cumulative proportion of the population ordered by pared with women having low enlightenment (AOR = household wealth quintiles and maternal education. 4.55; 95% CI 1.41, 14.69 and AOR = 5.49; 95% CI 1.77, Concentration Index (CI) is positive when the Lorenz 17.00) Table 2. curve is below the line of equality indicating the concen- tration of ≥ 8 ANC contacts concentrates among high 3.3 Marginal effects of the factors associated with ≥ 8 socioeconomic groups and vice versa. The urban vs. ANC contacts rural place of residence was used for stratified analyses. In Table 3, marginal effect analysis was conducted to de- In the Lorenz curves, women were ranked according to cipher the effects of the factors associated with ≥ 8ANC ascending household wealth-related status to estimate contacts. From the predictive marginal effects results, as- their position in the cumulative distribution of socioeco- suming the distribution of all factors remained the same nomic status. Conventionally, when it is applied to bin- among women, but every woman had low neighborhood ary indicators, the concentration index depends on the socioeconomic disadvantaged status, we would expect Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 5 of 12 Table 1 Characteristics of women attending ≥ 8 ANC contacts in Benin, West Africa, BDHS 2017–18 Variable ≥ 8 ANC visits Total P value No (92.0%) Yes (8.0%) Maternal age 15–19 116 (95.9) 5 (4.1) 121 0.219 20–24 260 (92.9) 20 (7.1) 280 25–29 284 (90.5) 30 (9.5) 314 30–34 181 (89.2) 22 (10.8) 203 35–39 111 (93.3) 8 (6.7) 119 40–44 38 (95.0) 2 (5.0) 40 45–49 17 (100.0) 0 (0.0) 17 Neighborhood socioeconomic disadvantaged status Tertile 1 (least disadvantaged) 309 (85.1) 54 (14.9) 363 < 0.001* Tertile 2 342 (93.4) 24 (6.6) 366 Tertile 3 (most disadvantaged) 356 (97.5) 9 (2.5) 365 Women’s enlightenment level Low 422 (97.5) 11 (2.5) 433 < 0.001* Medium 291 (91.2) 28 (8.8) 319 High 315 (92.1) 27 (7.9) 342 Decision-making power Low 273 (94.8) 15 (5.2) 288 0.022* Medium 213 (89.1) 26 (10.9) 239 High 85 (87.6) 12 (12.4) 97 Age at first marriage (years) < 18 377 (94.3) 23 (5.7) 400 0.029* 18–24 521 (91.7) 47 (8.3) 568 > 24 74 (86.1) 12 (13.9) 86 Family type Monogyny 624 (90.8) 63 (9.2) 687 0.017* Polygyny 326 (95.0) 17 (5.0) 343 Timing of ANC initiation Early booking (within 1st trimester) 441 (85.1) 77 (14.9) 518 < 0.001* Late booking (after 1st trimester) 440 (99.5) 2 (0.5) 442 Number of children ever born 1–3 565 (90.7) 58 (9.3) 623 0.056 > 3 442 (93.8) 29 (6.2) 471 Birth order 1st 210 (88.2) 28 (11.8) 238 0.042* 2nd 174 (92.1) 15 (7.9) 189 3rd 181 (92.3) 15 (7.7) 196 4th 149 (90.8) 15 (9.2) 164 > 4th 293 (95.4) 14 (4.6) 307 Preceding birth interval First birth 212 (87.6) 30 (12.4) 242 0.002* < 24 months 114 (99.1) 1 (0.9) 115 24–36 months 337 (92.3) 28 (7.7) 365 Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 6 of 12 Table 1 Characteristics of women attending ≥ 8 ANC contacts in Benin, West Africa, BDHS 2017–18 (Continued) Variable ≥ 8 ANC visits Total P value No (92.0%) Yes (8.0%) > 36 months 344 (92.5) 28 (7.5) 372 Religion Christianity 457 (88.2) 61 (11.8) 518 < 0.001* Islam 383 (96.7) 13 (3.3) 396 Traditional and others 167 (92.8) 13 (7.2) 180 Sex of head of household Male 856 (92.2) 72 (7.8) 928 0.575 Female 151 (91.0) 15 (9.0) 166 Ever had a terminated pregnancy Yes 93 (87.7) 13 (12.3) 106 0.084 No 914 (92.5) 74 (7.5) 988 Health insurance coverage Not covered 1001 (92.3) 84 (7.7) 1085 < 0.001* Covered 5 (55.6) 4 (44.4) 9 Marital status Not married 35 (87.5) 5 (12.5) 40 0.523 Currently married/living with a partner 955 (92.2) 81 (7.8) 1036 Formerly married 17 (94.4) 1 (5.6) 18 Currently residing with husband/partner Living together 812 (92.2) 69 (7.8) 881 0.969 Staying elsewhere 143 (92.3) 12 (7.7) 155 Wanted pregnancy when became pregnant Then 731 (92.1) 63 (7.9) 794 0.992 Later 210 (92.1) 18 (7.9) 228 No more 66 (91.7) 6 (8.3) 72 *Significant at p < 0.05 11% of ≥ 8 ANC contacts. If every woman had high ma- ternal enlightenment or high decision-making power, we would expect 11% and 8% of ≥ 8 ANC contacts. If in- Table 2 Logistic regression of the factors associated with ≥ 8 stead the distribution of neighborhood socioeconomic ANC contacts among women of reproductive age in Benin, disadvantaged status, maternal enlightenment, and West Africa, BDHS 2017–2018 decision-making power were as observed and other co- Variable AOR 95% CI P variates remained the same among women, but no Timing to ANC contacts initiation woman had first marriage before age 25 years or had Early booking (within 1st trimester) 1.00 monogynous family life, we would expect about 10% and 9% of ≥ 8 ANC contacts respectively. Furthermore, if in- Late booking (after 1st trimester) 0.03 0.00–0.21 0.001* stead the spread of the aforementioned variables were as Women’s enlightenment level observed and other covariates remained equal among Low 1.00 women, but every woman initiated ANC contacts within Medium 4.55 1.41–14.69 0.011* 1st trimester were Christians or had health insurance High 5.49 1.77–17.00 0.003* coverage, we would expect 13%, 9%, and 16% of ≥ 8 Model adjusted for neighborhood socioeconomic disadvantaged level, ANC contacts respectively. In Table 3, we practically ob- decision-making power, age at 1st marriage, family type, preceding birth tained the predictive marginal effects of the factors asso- interval, religion, and health insurance coverage *Significant at p < 0.05 ciated with ≥ 8 ANC contacts. Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 7 of 12 Table 3 Marginal effect of the factors associated with the frequency of ANC visits among women of reproductive age in Benin, West Africa, BDHS 2017–2018 Variable Marginal effect 95% CI P Neighborhood socioeconomic disadvantaged status Tertile 1 (least disadvantaged) 0.11 0.07–0.15 < 0.001* Tertile 2 0.07 0.04–0.11 < 0.001* Tertile 3 (most disadvantaged) 0.05 0.01–0.09 0.018* Maternal enlightenment level Low 0.03 0.00–0.05 0.039* Medium 0.10 0.05–0.14 < 0.001* High 0.11 0.07–0.15 < 0.001* Decision-making power Low 0.08 0.04–0.12 < 0.001* Medium 0.09 0.06–0.12 < 0.001* High 0.08 0.04–0.13 0.001* Age at first marriage (years) < 18 0.08 0.04–0.13 < 0.001* 18–24 0.08 0.05–0.11 < 0.001* > 24 0.10 0.04–0.17 0.002* Family type Monogyny 0.09 0.06–0.12 < 0.001* Polygyny 0.07 0.03–0.11 < 0.001* Timing to ANC visits initiation Early booking (within 1st trimester) 0.13 0.10–0.17 < 0.001* Late booking (after 1st trimester) 0.01 − 0.01–0.02 0.315 Preceding birth interval First birth 0.10 0.04–0.16 0.001* < 24 months 0.02 − 0.02–0.05 0.310 24–36 months 0.09 0.05–0.12 < 0.001* > 36 months 0.10 0.06–0.13 < 0.001* Religion Christianity 0.09 0.07–0.12 < 0.001* Islam 0.06 0.02–0.10 0.004* Traditional and others 0.08 0.02–0.14 0.010* Health insurance coverage Not covered 0.08 0.06–0.10 < 0.001* Covered 0.16 0.02–0.30 0.029* *Significant at p < 0.05; McFadden’s R-squared for model fitness = 0.28 3.4 Socioeconomic inequalities (Lorenz curve and group and maternal education had higher ≥ 8ANC concentration index) contacts. Figures 1, 2, 3, 4 showed the household wealth-related In Table 4, we presented the coverage of ≥ 8ANC and maternal education inequalities for women of repro- contacts across household wealth quintile and maternal ductive age who had ≥ 8 ANC contacts in Benin, West education. Overall, the richest women and higher mater- Africa. The farther the Lorenz curves sags away from nal education had the highest coverage of ≥ 8 ANC con- the line of equality, the greater the degree of inequalities. tacts. Using Concentration Index, we quantified the The curves revealed that women from higher wealth degree of wealth-related and maternal education Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 8 of 12 Fig. 1 Urban-rural differential in household wealth-related inequalities of ≥ 8 ANC contacts inequalities in ≥ 8 ANC contacts. The outcome (≥ 8 ANC and whether the recommendation in the guideline has been contacts) was significantly more in the higher household implemented or influenced policy decisions. The recom- wealth groups and maternal education, specifically among mendation requires that the first ANC contact should take the urban women and total sample: Household wealth- place in the first 12 weeks of gestation (within first trimester related factor: urban women—Conc. Index = 0.33; p < of the pregnancy); thereafter, two other contacts are sched- 0.001; total sample—Conc. Index = 0.37; p <0.001. Mater- uled to take place during the 20th and 26th weeks of gesta- nal education: urban women—Conc. Index = 0.18; p = tion (that is, during the second trimester of the pregnancy), 0.006; total sample—Conc. Index = 0.21; p <0.001). and the remaining five contacts are scheduled to place dur- ing the third trimester (precisely at 30th, 34th, 36th, 38th, and 40th weeks of gestation) [25]. 4 Discussion The results of this study revealed that after about 3 About 3 years (since November 2016) after the publication years of the launch of WHO minimum of 8 ANC con- and dissemination of ≥ 8 ANC contacts guideline, this sur- tacts model, less than one tenth (only 8.0%) of women in vey is the foremost to select respondents and gauges the Benin had at least 8 ANC contacts with the health care status and extent of in-country utilization and adaptation, Fig. 2 Urban-rural differential in maternal education inequalities of ≥ 8 ANC contacts Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 9 of 12 Fig. 3 Overall household wealth-related inequalities of ≥ 8 ANC contacts providers throughout the period of their pregnancy. In a In the marginal effects model, women from the least previous study, which examined the coverage of mini- socioeconomic disadvantaged neighborhood were found mum 4 ANC visits in Benin, the findings from 2006 and to have had higher predictive value of ≥ 8 ANC contacts. 2012 data showed the coverage were about 61.0% and This can be viewed in the light that women who live in higher than the current minimum of 8 ANC contacts an economic advantaged neighborhood may be well-off, [13]. This result clearly showed that the new WHO 8 more enlightened, and have more access to health facil- ANC contacts model is yet to be institutionalized or ac- ity than those living in economically disadvantaged cepted among women of childbearing age in Benin Re- neighborhood. The pro-rich neighborhood is commonly public. It is most likely that supply-side and demand- where the members of richest wealth quintile, educated, side factors could be responsible for this low minimum and the affluent members of a given society dwell. These of 8 ANC contacts uptake. For example, lack of behavior areas are commonly equipped with the best of health change communication/awareness, poor health care sys- care, technology, and education compared with the poor tem, or lack of buy-in by stakeholders in health system or socioeconomically most disadvantaged areas. This including the providers can be linked to this staggering phenomenon abounds in most parts of SSA countries. outcome. The reason for the inability to have maximum ANC Fig. 4 Overall maternal education inequalities of ≥ 8 ANC contacts Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 10 of 12 Table 4 Prevalence and Concentration Index of ≥ 8 ANC wealth status had greater uptake of ANC contacts as rec- contacts by household wealth quintile and maternal education, ommended in the new guideline. BDHS, 2017-18 The enlightenment level of pregnant women was also Variable Urban Rural Total found to be correlated with ≥ 8 ANC contacts. Improved Household wealth quintile (%) enlightenment levels usually result from exposure to educational materials, listening to news, watching televi- Poorest 1.5 5.6 4.4 sion, reading newspapers, and passing through a formal Poorer 6.8 2.1 3.0 education. This may be related to the knowledge of the Middle 12.5 4.1 6.2 importance of registering for ANC and also completing Richer 5.1 4.4 4.7 at least 8 ANC contacts. These factors have previously Richest 22.7 20.0 22.2 been reported to positively influence optimal utilization Overall 12.9 4.9 8.0 of ANC among women in Benin [30] and in rural Malawi [31]. Moreover, we observed that high decision- Concentration Index 0.33 0.16 0.37 making power is a factor that increased at least 8 ANC SE 0.07 0.10 0.06 contacts. This factor could result from increased auton- P value < 0.001* 0.087 < 0.001* omy for the women, more access to health information, Urban-rural comparison and an enhanced economic and monetary status [12]. z-stat − 1.46 Therefore, it is important that the girl child should be CI difference − 0.17 educated up to post-secondary school level and empow- ered for greater independence such that the issues con- P value 0.143 cerning her health needs especially the reproductive Maternal education (%) aspect will be decisively taken by her. In addition, more No education 9.1 3.7 5.5 communication through using mass media providing in- Primary 16.5 8.9 11.9 formation about the importance of this new ANC model Secondary 14.2 3.3 9.1 would be helpful in facilitating behavior change [32]. The Tertiary 50.0 40.0 47.1 multivariable logit model shows that women who were highly or moderately enlightened were more likely to have Overall 12.9 4.9 8.0 8 or more antenatal care contacts. Education or enlighten- Concentration Index 0.18 0.15 0.21 ment has been reported to be a protective factor that en- SE 0.07 0.08 0.05 hances women’s utilization of health care services as well P value 0.006* 0.067 < 0.001* as reproductive health decision-making [33, 34]. Urban-rural comparison Women who married after age 24 years had higher z-stat − 0.34 predictive values of at least 8 ANC contacts. This finding is in agreement with the report of a previous study CI difference − 0.03 β where the majority of the pregnant women who had P value 0.734 good utilization of ANC contacts had their marriage α β P value and P value were obtained using the Concentration Index for overall after adolescent age [35]. The explanations could be that inequalities across socioeconomic groups and measuring rural vs. urban differences respectively the delay of timing to marriage may be due to spending SE standard error more time in educational institution or career develop- *Significant at p < 0.05 ment [36], which is a measure of improving women’s empowerment. These folks could have better knowledge contacts has over the years been linked to financial con- of the benefits of optimal ANC contacts during preg- straints, poor access to health facility, lack of decision- nancy which is in line with reports from previous studies making power as regard to reproductive health matters, [35, 37]. Education is one of the major ways to empower proximity to health facility, and so forth [12, 26–28]. women. It provides them with higher assurance and These factors that are linked to low frequency of ANC competence to make decisions in the use of available contacts should be of great concern to policy makers modern health care services for themselves and their and funding agencies. Some studies have acknowledged children [33]. lack of knowledge of the importance of ANC contacts, In addition, women who initiated ANC early or at the ignorance of the time to start ANC contacts, as reasons first trimester of pregnancy had higher predictive value for underutilization of ANC in general [12, 27, 29]. This of ≥ 8 ANC contacts. Also, in the logit model, it was finding corroborates with the present results from the found that late booking for ANC had large reduction in analysis of socioeconomic inequalities, where the edu- the odds of having at least 8 ANC contacts during preg- cated women and those from households with high nancy. Similarly, the findings from previous studies Ekholuenetale et al. Journal of the Egyptian Public Health Association (2020) 95:13 Page 11 of 12 showed that early booking for ANC would result in opti- age to improve their understanding of the importance of mal number of ANC contacts during pregnancy [38]. the new model of care. Enlightening women and provid- Furthermore, women who had health insurance cover- ing support for early initiation of ANC contacts and in- age, monogynous family, long preceding birth interval or creasing equity-focused efforts will also help to improve first childbirth, and of Christian religious belief had in- the uptake of the minimum 8 ANC contacts. creased predictive values to the uptake of a minimum of Abbreviations 8 ANC contacts. ANC: Antenatal care; FANC: Focused antenatal care; MDGs: Millennium The findings from the socioeconomic inequalities of ≥ Development Goals; SDGs: Sustainable Development Goals; SSA: Sub-Saharan Africa; UN: United Nations; WHO: World Health Organization 8 ANC contacts revealed that women from non-poor households and the educated women had higher uptake Acknowledgements of ≥ 8 ANC contacts, especially in the urban residence. The authors appreciate the MEASURE DHS project for the approval and This is similar to previous results obtained for the access to the original data. utilization of maternal health care services in Benin [13]. Authors’ contributions The SDG-3 is known to support reduction in inequal- ME conceived and designed the study, performed data analysis, and wrote ities and ensure health for all populations. Therefore, be- the results. AB, CIN, and AO review the literature, wrote the discussion of the findings, and critically reviewed the manuscript for its intellectual content. All yond the utilization of ≥ 8 ANC to reach the most authors read and approved the final version of the manuscript. disadvantaged group of women, the uptake of maternal care services must be considered to achieve the set goals. Funding This research received no grant from any funding agency in the public, Strengthening health care programs and policies can en- commercial, or not-for-profit sectors. hance optimal ANC contacts uptake among women of reproductive age, as well as improve the utilization of Availability of data and materials maternal care services, particularly for the uneducated, Data for this study were sourced from Demographic and Health surveys (DHS) and available here: http://dhsprogram.com/data/available-datasets.cfm. low household wealth quintiles, and those who live in hard-to-reach rural residence. Ethics approval and consent to participate Ethics approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and 4.1 Strengths and limitations ethical standards are available at http://dhsprogram.com/data/available- This is the foremost nationwide analyses that explore datasets.cfm. Consent to participate is not applicable. the uptake of at least 8 ANC contacts in Benin and as such could serve as a benchmark and stimulus for fur- Consent for publication Demographic and Health Survey is a de-identified open-source dataset. ther nationwide studies on related subject matter. An- Therefore, the requirement of consent for publication is not applicable. other strength is the use of current nationally representative datasets which makes the findings of the Competing interests The authors declare that the research was conducted in the absence of any study generalizable to women of reproductive age in commercial or financial relationships that could be construed as a potential Benin. However, this analysis has some drawbacks. conflict of interest. Prominently, the analyses utilized cross-sectional data; Author details hence, only associations and no causal relationships Department of Epidemiology and Medical Statistics, Faculty of Public Health, could be established. Moreover, our inability to measure College of Medicine, University of Ibadan, Ibadan, Nigeria. Center of sources of demand-side unobserved heterogeneity across Excellence in Reproductive Health Innovation (CERHI), College of Medical Sciences, University of Benin, Benin City, Nigeria. Department of Public & the secondary data might have biased our estimates. The Environmental Health, School of Medicine & Allied Health Sciences, unavailability of relevant variables other than those col- University of The Gambia, Serekunda, Gambia. Project Management Unit, lected was a major limitation in the DHS data. Further- Management Sciences for Health, Abuja, Nigeria. more, recall bias could have occurred due to the self- Received: 30 August 2019 Accepted: 30 April 2020 reported number of ANC contacts. 5 Conclusion References 1. World Health Organization. Make every mother and child count. The world Analysis of the BDHS showed low coverage of ≥ 8ANC health report. 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Journal of the Egyptian Public Health AssociationSpringer Journals

Published: Jun 3, 2020

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