Inequalities in maternal health care utilization in Benin: a population based cross-sectional study

Inequalities in maternal health care utilization in Benin: a population based cross-sectional study Background: Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio- demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes. Methods: This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15–49 years in 2006 and 2012 respectively. Women’s characteristics were reported in percentage, mean and standard deviation. Results: Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13–1.52), 1.69 (OR = 1.69; 95% CI = 1.20–2.37) and 1.38 (OR = 1.38; 95% CI = 1.16–1.65) times as likely to utilize maternal health care services after adjusting for other covariates. Conclusion: The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to- reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage. Keywords: Antenatal care, Postnatal care, Contraceptive use, Institutional delivery, Inequalities, Benin, Demographic and health survey, Cross-sectional study * Correspondence: sanni.yaya@uOttawa.ca School of International Development and Global Studies, University of Ottawa, Ottawa, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 2 of 9 Background Essential emergency obstetric health care services are The steps towards achieving the third United Nations required to access key equitable resources across re- (UN) Sustainable Development Goals (SDGs), to reduce gions, socio-economic strata and geographical locations maternal morbidity and mortality and achieve universal [11]. Maternal health care services encompass a wide health coverage to include access to essential health care range of clinical procedures and care provided to women services by 2030 have been a great issue in developing during pregnancy. As a matter of necessity, all pregnant countries, even with the existence of health care interven- women should have access to quality antenatal care re- tions. Though there are numerous health care implemen- gardless of their economic, cultural, geographical and so- tation projects to promote safe motherhood worldwide, cial background. Interestingly, antenatal care performs a maternal morbidity and mortality remain a notable hitch crucial role in ensuring a healthy baby and mother during in health care programme and policy making particu- pregnancy and after delivery. This care is given to preg- larly in low-income countries. In spite of the vast ef- nant women to optimize quality health outcomes, such as forts by the global community to lessen the burden of normal birth weight, reduction in maternal and child mortality as a result of pregnancy and delivery, the rate death and low postpartum anemia [12]. More so, coun- of death due to pregnancy related complications is wor- tries that have achieved success in improving maternal risome [1]. Developing countries have been reported to health care services and reducing maternal morbidity account for about 99% of the global maternal mortality, mortality overall, are still faced with the challenges of while sub-Saharan Africa (SSA) countries record ap- large inequities among various sections of the popula- proximately 62% and having Maternal Mortality Ratio tions. The groups of women that are disadvantaged (MMR) of 510 maternal deaths per 100,000 live births tend to have more morbidity and mortality, and inad- [2, 3]. The challenge of unfair distribution of health equate access to safe motherhood services, acceptable care services is gaining global attention in the area of and affordable health care services to enhance safe public health, with evidence of the disadvantaged sec- pregnancy and delivery [13]. Efforts have been made to tions of the society, having worst health conditions [1]. reduce health inequities across all facets of the popula- Like other sub-Saharan countries, Benin is having an tions, on subnational, national and global levels, and unfair share in maternal health care. A country with ensure equal opportunities to all members of communities Total Fertility Rate (TFR) of 5.3, is ranked the 34th in to achieve good health [14]. However, most health care the world with maternal death [4]. systems are inequitable, benefiting the wealthy than the Inadequate of access to antenatal, intrapartum and underprivileged [15]. postnatal health care services are among the prominent There are significant disparities in maternal health reasons for high maternal and child morbidities and care indicators across many geographical locations, ma- mortalities in SSA and the world at large [5, 6]. Maternal ternal, economic, socio-demographic factors in many health care services continue to be important indicators developing countries [16]. Whereas equity has been in- for monitoring the improvement of maternal health out- dicated as a prominent target within the health sectors, comes, as well as maternal mortality. In addition, ante- huge disparities exist in coverage of maternal and child natal care, institutional health delivery with skilled birth health care services between the well-off and disadvan- attendant, and postnatal care strengthen prompt man- taged in low income countries. The inequalities and agement and treatment of pregnancy related complica- inequities across various strata of the society have be- tions to reduce maternal mortality. Besides the benefits come key determinants of maternal and child health of institutional based delivery in the prevention of ma- [17, 18]. Obtaining equal access to maternal health care ternal death, more women give birth utilizing alternative including antenatal, delivery and postnatal services, is places such as home and Traditional Birth Attendants one of the most critical concerns in public health (TBA) who are not knowledgeable in modern obstetric programmes and policies shared in virtually everywhere care [7]. One of the major pillars of the Safe Mother- in the world, and demands that women with the same hood Initiative is antenatal care, which helps to provide maternal needs should receive the same access to interventions that are essential for positive pregnancy health care services [19]. outcomes [8]. World Health Organization (WHO) re- In this study, inequities in the determinants of major mark that receiving antenatal care not less than four maternal health outcomes including antenatal care, times increases the odds of receiving valuable health institutional delivery with skilled birth attendance and care promotion and preventive maternal health care in- utilization of modern contraception were examined terventions during antenatal visits [9, 10]. Furthermore, using Benin Demographic and Health Survey (BDHS) family planning is also a vital indicator of the Safe dataset. We presented comparative analyses of the out- Motherhood Initiative to reduce pregnancy related com- come variables in two separate BDHS to assess dispar- plications and death in developing countries [10]. ities in the utilization of these services. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 3 of 9 Methods Islam, traditional and other religion, while access to Data extraction health information was measured using frequency of Data for this study were derived from two rounds of reading newspaper or magazine, listening to radio and Demographic and Health Survey in Benin that provided watching TV. The wealth scores is obtained by princi- information on antenatal care, institutional delivery and pal components analysis, based on a list of household contraceptive use. The datasets have one record for assets as specified by DHS, which include, number of every eligible woman as defined by the household sched- household members, wall and roof materials, floor ule. The questionnaire contains all the data collected types, access to potable water and sanitation, type of from the individual woman for whom information on cooking fuel, ownership of television, radio, motorcycle, antenatal care, delivery and contraceptive usage and refrigerator amongst others. Based on the weighted some variables from the household were elicited. The wealth scores, households were grouped into five 2006 and 2012 Benin Demographic and Health Survey wealth quintiles; poorest, poorer, middle, richer and (BDHS) data contains 17,794 and 16,599 cases (units of richest. Furthermore, parity was measured by the num- analysis), which in this file is the woman. BDHS per- ber of children ever born by each individual woman; formed cross-sectional analyses using nationally represen- categorized as 1–4 and > 4 children. tative data, to collect information on demographic, health, and nutrition indicators. The survey is majorly funded by Ethical considerations the United States Agency for International Development We did the analyses using publicly available data from (USAID). The two rounds of BDHS utilized a multi-stage, demographic health surveys. Ethical procedures were stratified sampling design, with households as the sam- the responsibility of the institutions that commissioned, pling unit. Within each sample household, all eligible funded, or managed the surveys. All DHS surveys are women were interviewed [20]. approved by ICF international as well as an Institutional Review Board (IRB) in respective country to ensure that Outcome variables the protocols are in compliance with the U.S. Department In this study, we used four outcome measures of mater- of Health and Human Services regulations for the protec- nal health care utilization extracted from the BDHS. tion of human subjects. Firstly, we derived the; “number of antenatal care (ANC) visits during pregnancy”, this was grouped as 4 or more Statistical analysis ANC visits vs below 4 ANC visits. ANC visits is a measure Summary statistics including percentage and means of skilled pregnancy care received by women during most (±standard deviation) were used to examine the distribu- recent pregnancy. Secondly, we extracted the “place of de- tion of socio-demographic, economic distal and proximate livery (home vs health facility)”. This was measured as a maternal characteristics. To adjust for data representation, binary outcome for 1, if a woman delivered in a health fa- we used complex survey module (svyset) for all analyses cility (where skilled delivery attention is available) and 0, if to account for clustering, stratification and sample weight. otherwise. In addition, postnatal care was measured by In addition, the percentages of outcome variables were “respondents health’s checked after discharge/delivery at presented in bar chart. The factors associated with ANC home” Lastly, women’s “contraceptive use”; was obtained visits, facility-based delivery, postnatal care and contracep- as binary indicator taking 1 if the “woman ever used a tive use were examined using logistic regression models. contraceptive method” and 0, if otherwise. The bivariate analysis conducted to examine the factors that were added in the multivariable regression models in- Explanatory variables volved a simple regression with each explanatory variable. The utilization of ANC visits, facility-based delivery and Therefore, factors, which were statistically significant in contraceptive use are known to depend on a set of deter- the crude regression models, were added in the multivari- minants, such as demographic, economic, other proxim- able regression models to adjust for possible confounders. ate and social factors. Empirical literature on the factors An α level of 0.05 was considered statistically significant. pertinent to maternal health care services basically helped All analyses were conducted using STATA 14.0. to select the variables of study. These variables age of indi- vidual woman (15–19, 20–24, 25–29, 30–34, 35–39, 40– Results 44 and 45–49 year), geographical region (Alibori, Atacora, Sample characteristics Atlantique, Borgou, Collines, Couffo, Donga, Littoral, In this study, the characteristics of respondents were Mono, Queme, Plateau and Zou), type of residence (rural explored for 2006 and 2012 respectively. The mean ages vs urban). Educational attainment was categorized as of respondents were similar (29.0 ± 9.1/9.0) between the those having no formal education, primary, secondary and years of survey. The basic socio-demographic character- higher education. Religious beliefs included; Christianity, istics of the respondents were presented in Table 1. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 4 of 9 Table 1 Characteristics of respondents. Benin DHS 2006–12 Table 1 Characteristics of respondents. Benin DHS 2006–12 (Continued) Variable 2006 2012 Variable 2006 2012 n (17,794) % n (16,599) % n (17,794) % n (16,599) % Age (Mean ± SD) 29.0 ± 9.1 29.0 ± 9.0 Wealth index 15–19 3036 17.1 2922 17.6 Poorest 3357 18.9 3139 18.9 20–24 3117 17.5 2820 17.0 Poorer 3347 18.8 3274 19.7 25–29 3640 20.5 3147 19.0 Middle 3448 19.4 3433 20.7 30–34 2801 15.7 2720 16.4 Richer 3753 21.1 3511 21.2 35–39 2151 12.1 2185 13.2 Richest 3889 21.9 3242 19.5 40–44 1626 9.1 1667 10.0 Parity 45–49 1423 8.0 1138 6.9 1–4 8379 60.7 8377 66.9 Region > 4 5435 39.3 4145 33.1 Alibori 1197 6.7 1000 6.0 Women decision making power Atacora 1506 8.5 1476 8.9 Low 4140 35.1 2534 35.4 Atlantique 1988 11.2 1866 11.2 Moderate 7664 64.9 2741 38.2 Borgou 1535 8.6 1323 8.0 High 1892 26.4 Collines 1234 6.9 1256 7.6 Currently working Couffo 1530 8.6 1225 7.4 Yes 14,114 79.6 10,643 64.1 Donga 893 5.0 950 5.7 No 3628 20.4 5956 35.9 Littoral 1831 10.3 1949 11.7 Sex of household head Mono 1196 6.7 1043 6.3 Male 14,353 80.7 13,326 80.1 Quémé 2142 12.0 1811 10.9 Female 3441 19.3 3273 19.7 Plateau 862 4.8 1046 6.3 Zou 1880 10.6 1654 10.0 Type of place of residence Prevalence of maternal health care utilization. Urban 7471 42.0 7070 42.6 In this study, four outcomes were measured namely; antenatal care of at least 4 visits, facility-based deliv- Rural 10,323 58.0 9529 57.4 ery, postnatal care and utilization of contraceptive Educational attainment methods. The percentage of 4 or more antenatal visits No formal education 11,577 65.1 10,383 62.6 was 61.4% in 2006, and 61.1% in 2012, which showed Primary 3460 19.4 2766 16.7 that there was no increase in the level of antenatal Secondary 2595 14.6 3219 19.4 care visits over time. Facility-based delivery was re- Higher 162 0.9 231 1.4 ported as 88.6% in 2006 which had 4.9% increase by 2012. Postnatal care 15.2% in 2006, but increased to Religion 18.4% in 2012. Further, the percentage of contracep- Christianity 9484 53.4 9226 55.6 tive use was 17.2% in 2006, however reduced to 14% Islam 3878 21.8 3919 23.6 in 2016 (see Fig. 1 for details). Traditional 3178 17.9 2284 13.8 The results showed that women aged 35–49 years had Others 1210 6.8 1170 7.0 increase in the odds of facility-based delivery, compared Read newspaper/magazine to women aged 15–19 years. Further, women aged 45– 49 years had 45% significant reduction in the odds of Yes 1701 9.6 2140 12.9 contraceptive use, compared to women aged 15–19 years No 15,957 90.4 14,459 87.1 after adjusting for other covariates (OR = 0.55; 95% CI = Listen to radio 0.33–0.93). Also, geographical region was significantly Yes 14,499 81.7 10,525 63.4 associated with ANC visits, facility-based, postnatal care No 3257 18.3 6074 36.6 and contraceptive use. Rural women had 17% reduction Watch TV in the odds of contraceptive use, compared to the urban women after adjusting for other covariates (OR = 0.83; Yes 6398 36.1 7556 45.5 95% CI = 0.70–0.98). Educated women were more likely No 11,320 63.9 9043 54.5 to utilize ANC visits, facility-based and postnatal care, Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 5 of 9 Discussion Main findings This study has become the foremost to explore and exam- ine prominent indicators of maternal health care service utilization in Benin, and thus utilized two rounds of nationally representative data set from 2006 and 2012 surveys. The main outcome measures under study were ANC visits, institutional delivery, postnatal care and contraceptive use among women of reproductive age. The prevalence of ANC at least 4 or more visits, facility-based delivery, postnatal care and contraceptive use among Fig. 1 Prevalence of antenatal care, contraceptive use and facility-based women of reproductive age were relatively the same in delivery among women of reproductive age in Benin both rounds of survey. The estimates are consistent with literature from other sub-Saharan Africa countries where maternal health care indicators need more improvement compared to women with no formal education after [21–23]. Furthermore, socio-demographic, economic and adjusting for other covariates. proximate determinants were the main predictors of ma- Women with higher wealth index had significant in- ternal healthcare services. Age, geographical region, place crease in the odds of adequate ANC visits, facility-based of residence, level of education, religious beliefs, use of delivery and contraceptive use. Number of children ever media, wealth index and parity were significant predictors born was significantly associated with maternal health care for the disparity in access to skilled pregnancy care and services; women who had above 4 children had significant fertility control [22–25]. reduction in adequate ANC visits and facility-based deliv- In addition, this study found disparities in the ery respectively, compared to women who had 1–4chil- demographic, social, economic and proximate factors dren (ANC- OR = 0.71; 95% CI = 0.61–0.82; facility-based associated with the utilization of maternal health care delivery- OR = 0.59; 95% CI = 0.48–0.72). Notwithstand- services. The SDGs are known to support reduction in ing, women who had above 4 children were 1.48 times as inequalities and ensure health for all populations. In the likely to have contraceptive use, compared to women light of the above, beyond the utilization of maternal who had 1–4 children (OR = 1.48; 95% CI = 1.27–1.71). health care, also to reach the most disadvantaged group of Women with moderate decision-making power were the women, vis-a-vis the use of maternal care services 1.26 times as likely to have contraceptive use, compared must be considered to achieve the set goals [26]. The to women with low decision-making power. Also, findings in this study showed that women with lower edu- women from female headed households were 1.58 times cational level, inaccessibility of the media (newspaper, more likely to utilize facility-based delivery, compared radio and television), low economic class, rural dwellers to women from male headed households (OR = 1.58; amongst others are less likely to utilize maternal health- 95% CI = 1.18–2.11). See Table 2 for details. care services. This revealed disproportionate share of For 2012, women aged 45–49 years had higher odds maternal healthcare services by certain class of people of facility-based, compared to women aged 15–19 years despite of the high demand. The results were in line with after adjusting for other covariates. Respondents aged previous studies in other countries [27–30]. 35–44 years also had increase in the odds of contracep- Though there are interventions to improve coverage of tive use, compared to those aged 15–19 years. The region maternal and child health care services in sub-Saharan and religion of respondents was significantly associated Africa, the disparity in access and use by several factors with adequate ANC visits, facility-based delivery, postnatal such as place of residence, use of media, geographical re- care and contraceptive use. The respondents with high gion, educational attainment, age of women and wealth decision-making power were 1.47 times as likely to have quintile amongst others has remained persistently high facility-based delivery, compared to women with low in the two rounds of data utilized [30, 31]. Explaining decision-making power after adjusting for other covariates differentials in accessing maternal and reproductive (OR = 1.47; 95% CI = 1.03–2.10). Further, women who care services is a critical issue, because several other were currently working or employed had higher odds of contributory factors, including distance, cultural beliefs ANC visits, facility-based delivery and contraceptive use. or practices, health care seeking behavior, affordability Women from female headed households were 2.04 times and need for services must also be considered [31]. The as likely to have facility-based delivery, compared to other findings of this study were consistent with previous counterpart after adjusting for other covariates (OR = studies that reported that improvement in economic 2.04; 95% CI = 1.14–3.67). status was connected to better use of maternal health Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 6 of 9 Table 2 Odds ratios antenatal care visits, skilled birth delivery and contraceptive use for the years 2006 and 2012 Variable ANC Facility-based delivery Postnatal care Contraceptive use 2006 2012 2006 2012 2006 2012 2006 2012 Age 15–19 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 20–24 0.95 (0.69–1.29) 1.19 (0.93–1.52) 0.95 (0.62–1.47) 0.83 (0.31–2.22) 0.90 (0.61–1.33) 0.89 (0.54–1.48) 1.10 (0.69–1.75) 1.04 (0.85–1.28) 25–29 0.92 (0.68–1.26) 1.25 (0.98–1.58) 1.25 (0.83–1.88) 0.84 (0.32–2.21) 0.83 (0.57–1.21) 1.12 (0.70–1.79) 1.06 (0.67–1.68) 1.19 (0.97–1.47) 30–34 1.07 (0.77–1.49) 1.08 (0.85–1.37) 1.49 (0.96–2.32) 0.67 (0.23–1.91) 0.87 (0.58–1.29) 1.09 (0.67–1.77) 1.10 (0.68–1.77) 1.04 (0.83–1.29) 35–39 1.20 (0.85–1.69) 1.05 (0.82–1.35) 1.81 (1.10–2.97) 1.21 (0.42–3.50) 1.04 (0.67–1.59) 1.25 (0.76–2.04) 1.10 (0.67–1.80) 1.33 (1.06–1.68) 40–44 1.12 (0.76–1.66) 1.08 (0.81–1.43) 3.45 (1.96–6.10) 1.41 (0.48–4.18) 0.70 (0.43–1.15) 1.14 (0.64–2.01) 0.92 (0.56–1.52) 1.31 (1.04–1.65) 45–49 1.07 (0.72–1.59) 1.29 (0.86–1.94) 8.39 (4.74–14.83) 14.5 (3.55–59.41) 0.91 (0.52–1.61) 0.59 (0.25–1.37) 0.55 (0.33–0.93) 0.90 (0.69–1.16) Region Alibori 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Atacora 1.56 (0.99–2.46) 1.09 (0.73–1.60) 1.68 (0.99–2.82) 1.07 (0.49–2.33) 1.29 (0.70–2.38) 2.72 (1.59–4.66) 1.98 (1.16–3.36) 1.53 (0.79–2.96) Atlantique 3.14 (2.01–4.92) 0.87 (1.29–2.71) 31.1 (15.64–61.85) 5.37 (2.52–11.41) 0.22 (0.10–0.45) 1.43 (0.89–2.32) 5.18 (3.03–8.86) 0.81 (0.48–1.37) Borgou 1.69 (1.02–2.80) 0.93 (0.65–1.34) 1.14 (0.65–2.00) 0.97 (0.54–1.72) 0.37 (0.20–0.71) 2.85 (1.71–4.74) 1.63 (0.95–2.81) 1.61 (1.02–2.55) Collines 2.02 (1.28–3.19) 1.30 (0.87–1.94) 5.63 (2.96–10.69) 3.39 (1.38–8.36) 0.91 (0.47–1.75) 3.77 (2.82–6.24) 5.12 (3.04–8.64) 1.67 (0.96–2.92) Couffo 1.55 (0.98–2.43) 2.07 (1.39–3.11) 2.64 (1.51–4.63) 1.78 (0.76–4.19) 1.04 (0.52–2.10) 1.29 (0.72–2.32) 1.67 (0.94–2.96) 1.58 (0.95–2.62) Donga 1.57 (0.97–2.55) 0.92 (0.61–1.39) 1.85 (1.01–3.82) 1.46 (0.61–3.53) 1.80 (1.01–3.21) 1.60 (0.86–3.00) 1.04 (0.59–1.84) 0.47 (0.26–0.84) Littoral 3.88 (2.24–6.73) 1.49 (0.98–2.26) 7.80 (3.13–19.14) 1.50 (0.46–4.89) 1.29 (0.53–3.13) 2.27 (1.36–3.80) 2.69 (1.57–4.62) 1.32 (0.81–2.17) Mono 2.32 (1.44–3.72) 2.74 (1.77–4.24) 9.24 (4.46–19.14) 14.75 (4.74–45.88) 1.23 (0.63–2.42) 2.47 (1.41–4.32) 1.55 (0.89–2.72) 0.39 (0.22–0.67) Quémé 2.60 (1.69–3.99) 2.84 (1.94–4.18) 28.60 (14.52–56.33) 35.33 (4.67–267.4) 0.41 (0.20–0.85) 2.30 (1.46–3.63) 3.00 (1.81–4.96) 0.62 (0.38–0.99) Plateau 2.07 (1.31–3.29) 0.74 (0.49–1.13) 4.38 (2.46–7.81) 1.38 (0.61–3.12) 0.77 (0.35–1.70) 1.83 (0.76–4.40) 0.98 (0.53–1.81) 1.33 (0.79–2.24) Zou 2.85 (1.81–4.49) 2.42 (1.64–3.55) 19.49 (10.48–36.24) 8.47 (3.66–19.61) 0.57 (0.28–1.17) 1.03 (0.61–1.73) 1.96 (1.15–3.32) 1.32 (0.78–2.23) Type of place of residence Urban 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Rural 1.02 (0.86–1.24) 1.01 (0.85–1.19) 0.93 (0.64–1.34) 0.68 (0.42–1.10) 0.82 (0.61–1.10) 0.86 (0.67–1.09) 0.83 (0.70–0.98) 1.17 (0.94–1.47) Educational attainment No formal education 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Primary 1.29 (1.08–1.53) 1.63 (1.39–1.92) 2.12 (1.56–2.89) 1.97 (1.20–3.26) 1.04 (0.75–1.45) 0.91 (0.68–1.23) 1.42 (1.22–1.65) 1.33 (1.14–1.56) Secondary 1.28 (0.91–1.79) 2.13 (1.69–2.68) 5.79 (1.89–17.72) 3.40 (1.25–9.24) 1.08 (0.57–2.08) 1.12 (0.75–1.68) 1.95 (1.59–2.38) 1.87 (1.55–2.25) Higher 2.60 (0.90–7.54) 15.35 (0.95–247.2) 1.16 (0.24–5.55) 1.16 (0.68–1.97) 2.09 (1.35–3.26) Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 7 of 9 Table 2 Odds ratios antenatal care visits, skilled birth delivery and contraceptive use for the years 2006 and 2012 (Continued) Variable ANC Facility-based delivery Postnatal care Contraceptive use 2006 2012 2006 2012 2006 2012 2006 2012 Religion Christianity 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Islam 0.76 (0.61–0.95) 0.80 (0.67–0.96) 0.60 (0.45–0.81) 0.59 (0.39–0.90) 0.84 (0.55–1.29) 0.87 (0.68–1.12) 0.83 (0.68–1.02) 1.29 (1.08–1.55) Traditional 0.81 (0.67–0.97) 0.68 (0.57–0.82) 0.48 (0.35–0.64) 0.57 (0.32–1.02) 1.30 (0.97–1.75) 1.07 (0.77–1.49) 0.86 (0.69–1.08) 0.80 (0.63–0.99) Others 0.80 (0.64–0.98) 0.70 (0.56–0.88) 0.53 (0.39–0.73) 0.56 (0.34–0.92) 1.33 (0.91–1.94) 0.84 (0.58–1.3) 0.71 (0.55–0.92) 0.64 (0.46–0.88) Read newspaper/magazine 1.19 (0.78–1.82) 0.89 (0.68–1.16) 0.85 (0.37–1.94) 0.62 (0.22–1.76) 1.07 (0.53–2.18) 1.31 (0.83–2.05) 1.46 (1.17–1.81) 0.89 (0.75–1.07) Listen to radio 1.36 (1.17–1.57) 0.96 (0.84–1.10) 1.38 (1.13–1.70) 1.29 (0.93–1.78) 0.98 (0.76–1.26) 1.06 (0.83–1.36) 1.39 (1.14–1.68) 1.16 (1.01–1.34) Watch TV 1.39 (1.18–1.63) 1.31 (1.13–1.52) 1.49 (1.13–1.97) 1.69 (1.20–2.37) 1.56 (1.13–2.15) 0.99 (0.79–1.23) 1.28 (1.08–1.52) 1.38 (1.16–1.65) Wealth index Poorest 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Poorer 1.39 (1.18–1.63) 1.36 (1.15–1.60) 2.02 (1.67–2.45) 1.55 (1.13–2.13) 1.22 (0.95–1.56) 0.82 (0.61–1.10) 1.27 (1.01–1.60) 1.06 (0.83–1.34) Middle 1.86 (1.58–2.20) 1.78 (1.51–2.11) 2.97 (2.38–3.72) 2.36 (1.63–3.43) 0.95 (0.72–1.25) 0.91 (0.67–1.22) 1.40 (1.11–1.76) 1.19 (0.94–1.51) Richer 2.64 (2.19–3.17) 2.62 (2.15–3.20) 7.36 (5.31–10.18) 7.14 (4.08–12.49) 1.06 (0.76–1.48) 0.86 (0.61–1.23) 1.48 (1.16–1.87) 1.10 (0.85–1.43) Richest 5.19 (3.96–6.80) 3.71 (2.78–4.94) 13.04 (7.10–23.95) 21.63 (7.30–64.08) 1.67 (1.09–1.60) 1.16 (0.79–1.70) 2.07 (1.59–2.71) 1.14 (0.85–1.54) Parity 1–4 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 > 4 0.71 (0.61–0.82) 0.93 (0.84–1.04) 0.59 (0.48–0.72) 0.78 (0.58–1.04) 1.01 (0.84–1.21) 1.03 (0.84–1.25) 1.48 (1.27–1.71) 1.06 (0.94–1.21) Women decision making power Low 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Moderate 1.04 (0.91–1.19) 1.02 (0.86–1.21) 0.91 (0.74–1.12) 0.96 (0.70–1.31) 0.97 (0.74–1.27) 0.76 (0.55–1.06) 1.26 (1.10–1.44) 0.97 (0.81–1.18) High 1.22 (1.01–1.47) 1.47 (1.03–2.10) 1.12 (0.77–1.63) 1.04 (0.85–1.27) Currently working 1.10 (0.94–1.28) 1.71 (1.49–1.95) 0.69 (0.55–0.86) 2.52 (1.51–4.22) 1.09 (0.78–1.53) 0.87 (0.71–1.07) 0.97 (0.87–1.08) 1.37 (1.21–1.56) Sex of household head Male 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Female 1.11 (0.92–1.33) 1.09 (0.92–1.30) 1.58 (1.18–2.11) 2.04 (1.14–3.67) 1.11 (0.82–1.51) 1.02 (0.75–1.37) 1.13 (1.00–1.26) 1.12 (0.98–1.28) N.B. Numbers represent odds ratios. Ref = reference category Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 8 of 9 services [10]. Again, religious beliefs and residency usu- The Benin government needs to create strategies that ally indicate cultural background and influence norms, cover both the supply and demand side interventions, values and beliefs in relation to women’s status, service specifically to reach the uneducated, living in remote areas use and childbirth. Previous studies have reported low with inadequate resources to have access to health care levels of maternal healthcare utilization among ethnic services. Such strategy must go beyond any specific inter- minority women in rural areas [32–34]. Also, maternal vention for maternal health care to accommodate a wider decision-making power was associated with health care developmental agenda and human capital development. behaviors. Women’s empowerment enhance the know- Abbreviations ledge and need of health care and awareness of services ANC: Antenatal care; DHS: Demographic Health Survey; IRB: Institutional which can improve through behavior change communi- Review Board; MMR: Maternal Mortality Ratio; SDGs: Sustainable Development Goals; SSA: Sub-Saharan Africa; TBA: Traditional Birth Attendant; cation and increase the ability of a woman to have posi- USAID: United States Agency for International Development; WHO: World tive health care-seeking behavior. Overall, our study is Health Organization consistent with the findings from a review of numerous Acknowledgments studies in developing countries that women’s empower- The authors thank the MEASURE DHS project for their support and for free ment is positively associated with the use of maternal access to the original data. health care services [35]. Funding The authors have no support or funding to report. Strengths and limitations The main strength of this study is that it leverages on Availability of data and materials nationally representative data collected through a consist- Data for this study were sourced from Benin Demographic and Health surveys (DHS) and available here: https://dhsprogram.com/what-we-do/ ent methodology in 2006 and 2011–12. In addition, this is survey/survey-display-420.cfm and here: https://dhsprogram.com/what-we- the foremost nationwide analyses that explores antenatal do/survey/survey-display-491.cfm visits, facility-based delivery, postnatal and contraceptive Authors’ contributions utilization in Benin, and as such could serve as benchmark SY and ME contributed to the study design, the review of literature, and and stimulus for further nationwide studies on related analysis of literature, manuscript conceptualisation and preparation. OU, AA subjects. Nonetheless, cross sectional data are unable to and GB critically reviewed the manuscript for its intellectual content. SY had final responsibility to submit for publication. All authors read and approved sufficiently establish causality, again due to self-report the final manuscript. method of eliciting information from respondents, there could be possibility of recall bias which could affect the Ethics approval and consent to participate Ethics approval for this study was not required since the data is secondary level of utilization of maternal health care services re- and is available in the public domain. More details regarding DHS data and ported in this study. ethical standards are available at: http://goo.gl/ny8T6X. Conclusion Consent for publication No consent to publish was needed for this study as we did not use any This study has identified the importance of vital maternal details, images or videos related to individual participants. In addition data care services and associated socio-demographic, economic used is available in the public domain. and proximate factors disparities against the backdrop of Competing interests poor maternal health indicators in Benin. The findings The authors declare that they have no competing interests. showed consistent differentials in the use of key maternal health services, such as ANC visits, facility-based delivery, Publisher’sNote postnatal care and contraceptive use, in favor of women in Springer Nature remains neutral with regard to jurisdictional claims in urban, educated, high economic status and use of media. published maps and institutional affiliations. Though the study revealed disparities in selected determi- Author details nants of maternal care services in Benin, however, there School of International Development and Global Studies, University of are other factors such as environmental conditions, gov- Ottawa, Ottawa, Canada. Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, ernance, culture, infrastructure and availability of medical University of Warwick, Coventry CV4 7AL, UK. Bloomberg School of Public equipment and personnel that play vital role in reduction Health, Johns Hopkins University, Baltimore, MD, USA. Department of of these differences. Hence, the findings would guide Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria. stakeholders in health care system to address the unequal access in health care services. As we strive for universal Received: 14 February 2018 Accepted: 23 May 2018 health coverage, health care interventions, programmes and policies should be strengthened to enhance maternal References care services utilization, and tackle the disparities in the 1. Yaya S, Bishwajit G, Shah V. 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Barriers to utilisation of maternal health services in a semiurban community in northern Nigeria: the clients’ perspective. Niger Med J. 2013;54(1):27–32. 25. Mpembeni RN, Killewo JZ, Leshabari MT. Use pattern of maternal health services and determinants of skilled care during delivery in southern http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Pregnancy and Childbirth Springer Journals

Inequalities in maternal health care utilization in Benin: a population based cross-sectional study

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Medicine & Public Health; Reproductive Medicine; Maternal and Child Health; Gynecology
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Abstract

Background: Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio- demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes. Methods: This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15–49 years in 2006 and 2012 respectively. Women’s characteristics were reported in percentage, mean and standard deviation. Results: Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13–1.52), 1.69 (OR = 1.69; 95% CI = 1.20–2.37) and 1.38 (OR = 1.38; 95% CI = 1.16–1.65) times as likely to utilize maternal health care services after adjusting for other covariates. Conclusion: The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to- reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage. Keywords: Antenatal care, Postnatal care, Contraceptive use, Institutional delivery, Inequalities, Benin, Demographic and health survey, Cross-sectional study * Correspondence: sanni.yaya@uOttawa.ca School of International Development and Global Studies, University of Ottawa, Ottawa, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 2 of 9 Background Essential emergency obstetric health care services are The steps towards achieving the third United Nations required to access key equitable resources across re- (UN) Sustainable Development Goals (SDGs), to reduce gions, socio-economic strata and geographical locations maternal morbidity and mortality and achieve universal [11]. Maternal health care services encompass a wide health coverage to include access to essential health care range of clinical procedures and care provided to women services by 2030 have been a great issue in developing during pregnancy. As a matter of necessity, all pregnant countries, even with the existence of health care interven- women should have access to quality antenatal care re- tions. Though there are numerous health care implemen- gardless of their economic, cultural, geographical and so- tation projects to promote safe motherhood worldwide, cial background. Interestingly, antenatal care performs a maternal morbidity and mortality remain a notable hitch crucial role in ensuring a healthy baby and mother during in health care programme and policy making particu- pregnancy and after delivery. This care is given to preg- larly in low-income countries. In spite of the vast ef- nant women to optimize quality health outcomes, such as forts by the global community to lessen the burden of normal birth weight, reduction in maternal and child mortality as a result of pregnancy and delivery, the rate death and low postpartum anemia [12]. More so, coun- of death due to pregnancy related complications is wor- tries that have achieved success in improving maternal risome [1]. Developing countries have been reported to health care services and reducing maternal morbidity account for about 99% of the global maternal mortality, mortality overall, are still faced with the challenges of while sub-Saharan Africa (SSA) countries record ap- large inequities among various sections of the popula- proximately 62% and having Maternal Mortality Ratio tions. The groups of women that are disadvantaged (MMR) of 510 maternal deaths per 100,000 live births tend to have more morbidity and mortality, and inad- [2, 3]. The challenge of unfair distribution of health equate access to safe motherhood services, acceptable care services is gaining global attention in the area of and affordable health care services to enhance safe public health, with evidence of the disadvantaged sec- pregnancy and delivery [13]. Efforts have been made to tions of the society, having worst health conditions [1]. reduce health inequities across all facets of the popula- Like other sub-Saharan countries, Benin is having an tions, on subnational, national and global levels, and unfair share in maternal health care. A country with ensure equal opportunities to all members of communities Total Fertility Rate (TFR) of 5.3, is ranked the 34th in to achieve good health [14]. However, most health care the world with maternal death [4]. systems are inequitable, benefiting the wealthy than the Inadequate of access to antenatal, intrapartum and underprivileged [15]. postnatal health care services are among the prominent There are significant disparities in maternal health reasons for high maternal and child morbidities and care indicators across many geographical locations, ma- mortalities in SSA and the world at large [5, 6]. Maternal ternal, economic, socio-demographic factors in many health care services continue to be important indicators developing countries [16]. Whereas equity has been in- for monitoring the improvement of maternal health out- dicated as a prominent target within the health sectors, comes, as well as maternal mortality. In addition, ante- huge disparities exist in coverage of maternal and child natal care, institutional health delivery with skilled birth health care services between the well-off and disadvan- attendant, and postnatal care strengthen prompt man- taged in low income countries. The inequalities and agement and treatment of pregnancy related complica- inequities across various strata of the society have be- tions to reduce maternal mortality. Besides the benefits come key determinants of maternal and child health of institutional based delivery in the prevention of ma- [17, 18]. Obtaining equal access to maternal health care ternal death, more women give birth utilizing alternative including antenatal, delivery and postnatal services, is places such as home and Traditional Birth Attendants one of the most critical concerns in public health (TBA) who are not knowledgeable in modern obstetric programmes and policies shared in virtually everywhere care [7]. One of the major pillars of the Safe Mother- in the world, and demands that women with the same hood Initiative is antenatal care, which helps to provide maternal needs should receive the same access to interventions that are essential for positive pregnancy health care services [19]. outcomes [8]. World Health Organization (WHO) re- In this study, inequities in the determinants of major mark that receiving antenatal care not less than four maternal health outcomes including antenatal care, times increases the odds of receiving valuable health institutional delivery with skilled birth attendance and care promotion and preventive maternal health care in- utilization of modern contraception were examined terventions during antenatal visits [9, 10]. Furthermore, using Benin Demographic and Health Survey (BDHS) family planning is also a vital indicator of the Safe dataset. We presented comparative analyses of the out- Motherhood Initiative to reduce pregnancy related com- come variables in two separate BDHS to assess dispar- plications and death in developing countries [10]. ities in the utilization of these services. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 3 of 9 Methods Islam, traditional and other religion, while access to Data extraction health information was measured using frequency of Data for this study were derived from two rounds of reading newspaper or magazine, listening to radio and Demographic and Health Survey in Benin that provided watching TV. The wealth scores is obtained by princi- information on antenatal care, institutional delivery and pal components analysis, based on a list of household contraceptive use. The datasets have one record for assets as specified by DHS, which include, number of every eligible woman as defined by the household sched- household members, wall and roof materials, floor ule. The questionnaire contains all the data collected types, access to potable water and sanitation, type of from the individual woman for whom information on cooking fuel, ownership of television, radio, motorcycle, antenatal care, delivery and contraceptive usage and refrigerator amongst others. Based on the weighted some variables from the household were elicited. The wealth scores, households were grouped into five 2006 and 2012 Benin Demographic and Health Survey wealth quintiles; poorest, poorer, middle, richer and (BDHS) data contains 17,794 and 16,599 cases (units of richest. Furthermore, parity was measured by the num- analysis), which in this file is the woman. BDHS per- ber of children ever born by each individual woman; formed cross-sectional analyses using nationally represen- categorized as 1–4 and > 4 children. tative data, to collect information on demographic, health, and nutrition indicators. The survey is majorly funded by Ethical considerations the United States Agency for International Development We did the analyses using publicly available data from (USAID). The two rounds of BDHS utilized a multi-stage, demographic health surveys. Ethical procedures were stratified sampling design, with households as the sam- the responsibility of the institutions that commissioned, pling unit. Within each sample household, all eligible funded, or managed the surveys. All DHS surveys are women were interviewed [20]. approved by ICF international as well as an Institutional Review Board (IRB) in respective country to ensure that Outcome variables the protocols are in compliance with the U.S. Department In this study, we used four outcome measures of mater- of Health and Human Services regulations for the protec- nal health care utilization extracted from the BDHS. tion of human subjects. Firstly, we derived the; “number of antenatal care (ANC) visits during pregnancy”, this was grouped as 4 or more Statistical analysis ANC visits vs below 4 ANC visits. ANC visits is a measure Summary statistics including percentage and means of skilled pregnancy care received by women during most (±standard deviation) were used to examine the distribu- recent pregnancy. Secondly, we extracted the “place of de- tion of socio-demographic, economic distal and proximate livery (home vs health facility)”. This was measured as a maternal characteristics. To adjust for data representation, binary outcome for 1, if a woman delivered in a health fa- we used complex survey module (svyset) for all analyses cility (where skilled delivery attention is available) and 0, if to account for clustering, stratification and sample weight. otherwise. In addition, postnatal care was measured by In addition, the percentages of outcome variables were “respondents health’s checked after discharge/delivery at presented in bar chart. The factors associated with ANC home” Lastly, women’s “contraceptive use”; was obtained visits, facility-based delivery, postnatal care and contracep- as binary indicator taking 1 if the “woman ever used a tive use were examined using logistic regression models. contraceptive method” and 0, if otherwise. The bivariate analysis conducted to examine the factors that were added in the multivariable regression models in- Explanatory variables volved a simple regression with each explanatory variable. The utilization of ANC visits, facility-based delivery and Therefore, factors, which were statistically significant in contraceptive use are known to depend on a set of deter- the crude regression models, were added in the multivari- minants, such as demographic, economic, other proxim- able regression models to adjust for possible confounders. ate and social factors. Empirical literature on the factors An α level of 0.05 was considered statistically significant. pertinent to maternal health care services basically helped All analyses were conducted using STATA 14.0. to select the variables of study. These variables age of indi- vidual woman (15–19, 20–24, 25–29, 30–34, 35–39, 40– Results 44 and 45–49 year), geographical region (Alibori, Atacora, Sample characteristics Atlantique, Borgou, Collines, Couffo, Donga, Littoral, In this study, the characteristics of respondents were Mono, Queme, Plateau and Zou), type of residence (rural explored for 2006 and 2012 respectively. The mean ages vs urban). Educational attainment was categorized as of respondents were similar (29.0 ± 9.1/9.0) between the those having no formal education, primary, secondary and years of survey. The basic socio-demographic character- higher education. Religious beliefs included; Christianity, istics of the respondents were presented in Table 1. Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 4 of 9 Table 1 Characteristics of respondents. Benin DHS 2006–12 Table 1 Characteristics of respondents. Benin DHS 2006–12 (Continued) Variable 2006 2012 Variable 2006 2012 n (17,794) % n (16,599) % n (17,794) % n (16,599) % Age (Mean ± SD) 29.0 ± 9.1 29.0 ± 9.0 Wealth index 15–19 3036 17.1 2922 17.6 Poorest 3357 18.9 3139 18.9 20–24 3117 17.5 2820 17.0 Poorer 3347 18.8 3274 19.7 25–29 3640 20.5 3147 19.0 Middle 3448 19.4 3433 20.7 30–34 2801 15.7 2720 16.4 Richer 3753 21.1 3511 21.2 35–39 2151 12.1 2185 13.2 Richest 3889 21.9 3242 19.5 40–44 1626 9.1 1667 10.0 Parity 45–49 1423 8.0 1138 6.9 1–4 8379 60.7 8377 66.9 Region > 4 5435 39.3 4145 33.1 Alibori 1197 6.7 1000 6.0 Women decision making power Atacora 1506 8.5 1476 8.9 Low 4140 35.1 2534 35.4 Atlantique 1988 11.2 1866 11.2 Moderate 7664 64.9 2741 38.2 Borgou 1535 8.6 1323 8.0 High 1892 26.4 Collines 1234 6.9 1256 7.6 Currently working Couffo 1530 8.6 1225 7.4 Yes 14,114 79.6 10,643 64.1 Donga 893 5.0 950 5.7 No 3628 20.4 5956 35.9 Littoral 1831 10.3 1949 11.7 Sex of household head Mono 1196 6.7 1043 6.3 Male 14,353 80.7 13,326 80.1 Quémé 2142 12.0 1811 10.9 Female 3441 19.3 3273 19.7 Plateau 862 4.8 1046 6.3 Zou 1880 10.6 1654 10.0 Type of place of residence Prevalence of maternal health care utilization. Urban 7471 42.0 7070 42.6 In this study, four outcomes were measured namely; antenatal care of at least 4 visits, facility-based deliv- Rural 10,323 58.0 9529 57.4 ery, postnatal care and utilization of contraceptive Educational attainment methods. The percentage of 4 or more antenatal visits No formal education 11,577 65.1 10,383 62.6 was 61.4% in 2006, and 61.1% in 2012, which showed Primary 3460 19.4 2766 16.7 that there was no increase in the level of antenatal Secondary 2595 14.6 3219 19.4 care visits over time. Facility-based delivery was re- Higher 162 0.9 231 1.4 ported as 88.6% in 2006 which had 4.9% increase by 2012. Postnatal care 15.2% in 2006, but increased to Religion 18.4% in 2012. Further, the percentage of contracep- Christianity 9484 53.4 9226 55.6 tive use was 17.2% in 2006, however reduced to 14% Islam 3878 21.8 3919 23.6 in 2016 (see Fig. 1 for details). Traditional 3178 17.9 2284 13.8 The results showed that women aged 35–49 years had Others 1210 6.8 1170 7.0 increase in the odds of facility-based delivery, compared Read newspaper/magazine to women aged 15–19 years. Further, women aged 45– 49 years had 45% significant reduction in the odds of Yes 1701 9.6 2140 12.9 contraceptive use, compared to women aged 15–19 years No 15,957 90.4 14,459 87.1 after adjusting for other covariates (OR = 0.55; 95% CI = Listen to radio 0.33–0.93). Also, geographical region was significantly Yes 14,499 81.7 10,525 63.4 associated with ANC visits, facility-based, postnatal care No 3257 18.3 6074 36.6 and contraceptive use. Rural women had 17% reduction Watch TV in the odds of contraceptive use, compared to the urban women after adjusting for other covariates (OR = 0.83; Yes 6398 36.1 7556 45.5 95% CI = 0.70–0.98). Educated women were more likely No 11,320 63.9 9043 54.5 to utilize ANC visits, facility-based and postnatal care, Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 5 of 9 Discussion Main findings This study has become the foremost to explore and exam- ine prominent indicators of maternal health care service utilization in Benin, and thus utilized two rounds of nationally representative data set from 2006 and 2012 surveys. The main outcome measures under study were ANC visits, institutional delivery, postnatal care and contraceptive use among women of reproductive age. The prevalence of ANC at least 4 or more visits, facility-based delivery, postnatal care and contraceptive use among Fig. 1 Prevalence of antenatal care, contraceptive use and facility-based women of reproductive age were relatively the same in delivery among women of reproductive age in Benin both rounds of survey. The estimates are consistent with literature from other sub-Saharan Africa countries where maternal health care indicators need more improvement compared to women with no formal education after [21–23]. Furthermore, socio-demographic, economic and adjusting for other covariates. proximate determinants were the main predictors of ma- Women with higher wealth index had significant in- ternal healthcare services. Age, geographical region, place crease in the odds of adequate ANC visits, facility-based of residence, level of education, religious beliefs, use of delivery and contraceptive use. Number of children ever media, wealth index and parity were significant predictors born was significantly associated with maternal health care for the disparity in access to skilled pregnancy care and services; women who had above 4 children had significant fertility control [22–25]. reduction in adequate ANC visits and facility-based deliv- In addition, this study found disparities in the ery respectively, compared to women who had 1–4chil- demographic, social, economic and proximate factors dren (ANC- OR = 0.71; 95% CI = 0.61–0.82; facility-based associated with the utilization of maternal health care delivery- OR = 0.59; 95% CI = 0.48–0.72). Notwithstand- services. The SDGs are known to support reduction in ing, women who had above 4 children were 1.48 times as inequalities and ensure health for all populations. In the likely to have contraceptive use, compared to women light of the above, beyond the utilization of maternal who had 1–4 children (OR = 1.48; 95% CI = 1.27–1.71). health care, also to reach the most disadvantaged group of Women with moderate decision-making power were the women, vis-a-vis the use of maternal care services 1.26 times as likely to have contraceptive use, compared must be considered to achieve the set goals [26]. The to women with low decision-making power. Also, findings in this study showed that women with lower edu- women from female headed households were 1.58 times cational level, inaccessibility of the media (newspaper, more likely to utilize facility-based delivery, compared radio and television), low economic class, rural dwellers to women from male headed households (OR = 1.58; amongst others are less likely to utilize maternal health- 95% CI = 1.18–2.11). See Table 2 for details. care services. This revealed disproportionate share of For 2012, women aged 45–49 years had higher odds maternal healthcare services by certain class of people of facility-based, compared to women aged 15–19 years despite of the high demand. The results were in line with after adjusting for other covariates. Respondents aged previous studies in other countries [27–30]. 35–44 years also had increase in the odds of contracep- Though there are interventions to improve coverage of tive use, compared to those aged 15–19 years. The region maternal and child health care services in sub-Saharan and religion of respondents was significantly associated Africa, the disparity in access and use by several factors with adequate ANC visits, facility-based delivery, postnatal such as place of residence, use of media, geographical re- care and contraceptive use. The respondents with high gion, educational attainment, age of women and wealth decision-making power were 1.47 times as likely to have quintile amongst others has remained persistently high facility-based delivery, compared to women with low in the two rounds of data utilized [30, 31]. Explaining decision-making power after adjusting for other covariates differentials in accessing maternal and reproductive (OR = 1.47; 95% CI = 1.03–2.10). Further, women who care services is a critical issue, because several other were currently working or employed had higher odds of contributory factors, including distance, cultural beliefs ANC visits, facility-based delivery and contraceptive use. or practices, health care seeking behavior, affordability Women from female headed households were 2.04 times and need for services must also be considered [31]. The as likely to have facility-based delivery, compared to other findings of this study were consistent with previous counterpart after adjusting for other covariates (OR = studies that reported that improvement in economic 2.04; 95% CI = 1.14–3.67). status was connected to better use of maternal health Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 6 of 9 Table 2 Odds ratios antenatal care visits, skilled birth delivery and contraceptive use for the years 2006 and 2012 Variable ANC Facility-based delivery Postnatal care Contraceptive use 2006 2012 2006 2012 2006 2012 2006 2012 Age 15–19 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 20–24 0.95 (0.69–1.29) 1.19 (0.93–1.52) 0.95 (0.62–1.47) 0.83 (0.31–2.22) 0.90 (0.61–1.33) 0.89 (0.54–1.48) 1.10 (0.69–1.75) 1.04 (0.85–1.28) 25–29 0.92 (0.68–1.26) 1.25 (0.98–1.58) 1.25 (0.83–1.88) 0.84 (0.32–2.21) 0.83 (0.57–1.21) 1.12 (0.70–1.79) 1.06 (0.67–1.68) 1.19 (0.97–1.47) 30–34 1.07 (0.77–1.49) 1.08 (0.85–1.37) 1.49 (0.96–2.32) 0.67 (0.23–1.91) 0.87 (0.58–1.29) 1.09 (0.67–1.77) 1.10 (0.68–1.77) 1.04 (0.83–1.29) 35–39 1.20 (0.85–1.69) 1.05 (0.82–1.35) 1.81 (1.10–2.97) 1.21 (0.42–3.50) 1.04 (0.67–1.59) 1.25 (0.76–2.04) 1.10 (0.67–1.80) 1.33 (1.06–1.68) 40–44 1.12 (0.76–1.66) 1.08 (0.81–1.43) 3.45 (1.96–6.10) 1.41 (0.48–4.18) 0.70 (0.43–1.15) 1.14 (0.64–2.01) 0.92 (0.56–1.52) 1.31 (1.04–1.65) 45–49 1.07 (0.72–1.59) 1.29 (0.86–1.94) 8.39 (4.74–14.83) 14.5 (3.55–59.41) 0.91 (0.52–1.61) 0.59 (0.25–1.37) 0.55 (0.33–0.93) 0.90 (0.69–1.16) Region Alibori 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Atacora 1.56 (0.99–2.46) 1.09 (0.73–1.60) 1.68 (0.99–2.82) 1.07 (0.49–2.33) 1.29 (0.70–2.38) 2.72 (1.59–4.66) 1.98 (1.16–3.36) 1.53 (0.79–2.96) Atlantique 3.14 (2.01–4.92) 0.87 (1.29–2.71) 31.1 (15.64–61.85) 5.37 (2.52–11.41) 0.22 (0.10–0.45) 1.43 (0.89–2.32) 5.18 (3.03–8.86) 0.81 (0.48–1.37) Borgou 1.69 (1.02–2.80) 0.93 (0.65–1.34) 1.14 (0.65–2.00) 0.97 (0.54–1.72) 0.37 (0.20–0.71) 2.85 (1.71–4.74) 1.63 (0.95–2.81) 1.61 (1.02–2.55) Collines 2.02 (1.28–3.19) 1.30 (0.87–1.94) 5.63 (2.96–10.69) 3.39 (1.38–8.36) 0.91 (0.47–1.75) 3.77 (2.82–6.24) 5.12 (3.04–8.64) 1.67 (0.96–2.92) Couffo 1.55 (0.98–2.43) 2.07 (1.39–3.11) 2.64 (1.51–4.63) 1.78 (0.76–4.19) 1.04 (0.52–2.10) 1.29 (0.72–2.32) 1.67 (0.94–2.96) 1.58 (0.95–2.62) Donga 1.57 (0.97–2.55) 0.92 (0.61–1.39) 1.85 (1.01–3.82) 1.46 (0.61–3.53) 1.80 (1.01–3.21) 1.60 (0.86–3.00) 1.04 (0.59–1.84) 0.47 (0.26–0.84) Littoral 3.88 (2.24–6.73) 1.49 (0.98–2.26) 7.80 (3.13–19.14) 1.50 (0.46–4.89) 1.29 (0.53–3.13) 2.27 (1.36–3.80) 2.69 (1.57–4.62) 1.32 (0.81–2.17) Mono 2.32 (1.44–3.72) 2.74 (1.77–4.24) 9.24 (4.46–19.14) 14.75 (4.74–45.88) 1.23 (0.63–2.42) 2.47 (1.41–4.32) 1.55 (0.89–2.72) 0.39 (0.22–0.67) Quémé 2.60 (1.69–3.99) 2.84 (1.94–4.18) 28.60 (14.52–56.33) 35.33 (4.67–267.4) 0.41 (0.20–0.85) 2.30 (1.46–3.63) 3.00 (1.81–4.96) 0.62 (0.38–0.99) Plateau 2.07 (1.31–3.29) 0.74 (0.49–1.13) 4.38 (2.46–7.81) 1.38 (0.61–3.12) 0.77 (0.35–1.70) 1.83 (0.76–4.40) 0.98 (0.53–1.81) 1.33 (0.79–2.24) Zou 2.85 (1.81–4.49) 2.42 (1.64–3.55) 19.49 (10.48–36.24) 8.47 (3.66–19.61) 0.57 (0.28–1.17) 1.03 (0.61–1.73) 1.96 (1.15–3.32) 1.32 (0.78–2.23) Type of place of residence Urban 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Rural 1.02 (0.86–1.24) 1.01 (0.85–1.19) 0.93 (0.64–1.34) 0.68 (0.42–1.10) 0.82 (0.61–1.10) 0.86 (0.67–1.09) 0.83 (0.70–0.98) 1.17 (0.94–1.47) Educational attainment No formal education 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Primary 1.29 (1.08–1.53) 1.63 (1.39–1.92) 2.12 (1.56–2.89) 1.97 (1.20–3.26) 1.04 (0.75–1.45) 0.91 (0.68–1.23) 1.42 (1.22–1.65) 1.33 (1.14–1.56) Secondary 1.28 (0.91–1.79) 2.13 (1.69–2.68) 5.79 (1.89–17.72) 3.40 (1.25–9.24) 1.08 (0.57–2.08) 1.12 (0.75–1.68) 1.95 (1.59–2.38) 1.87 (1.55–2.25) Higher 2.60 (0.90–7.54) 15.35 (0.95–247.2) 1.16 (0.24–5.55) 1.16 (0.68–1.97) 2.09 (1.35–3.26) Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 7 of 9 Table 2 Odds ratios antenatal care visits, skilled birth delivery and contraceptive use for the years 2006 and 2012 (Continued) Variable ANC Facility-based delivery Postnatal care Contraceptive use 2006 2012 2006 2012 2006 2012 2006 2012 Religion Christianity 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Islam 0.76 (0.61–0.95) 0.80 (0.67–0.96) 0.60 (0.45–0.81) 0.59 (0.39–0.90) 0.84 (0.55–1.29) 0.87 (0.68–1.12) 0.83 (0.68–1.02) 1.29 (1.08–1.55) Traditional 0.81 (0.67–0.97) 0.68 (0.57–0.82) 0.48 (0.35–0.64) 0.57 (0.32–1.02) 1.30 (0.97–1.75) 1.07 (0.77–1.49) 0.86 (0.69–1.08) 0.80 (0.63–0.99) Others 0.80 (0.64–0.98) 0.70 (0.56–0.88) 0.53 (0.39–0.73) 0.56 (0.34–0.92) 1.33 (0.91–1.94) 0.84 (0.58–1.3) 0.71 (0.55–0.92) 0.64 (0.46–0.88) Read newspaper/magazine 1.19 (0.78–1.82) 0.89 (0.68–1.16) 0.85 (0.37–1.94) 0.62 (0.22–1.76) 1.07 (0.53–2.18) 1.31 (0.83–2.05) 1.46 (1.17–1.81) 0.89 (0.75–1.07) Listen to radio 1.36 (1.17–1.57) 0.96 (0.84–1.10) 1.38 (1.13–1.70) 1.29 (0.93–1.78) 0.98 (0.76–1.26) 1.06 (0.83–1.36) 1.39 (1.14–1.68) 1.16 (1.01–1.34) Watch TV 1.39 (1.18–1.63) 1.31 (1.13–1.52) 1.49 (1.13–1.97) 1.69 (1.20–2.37) 1.56 (1.13–2.15) 0.99 (0.79–1.23) 1.28 (1.08–1.52) 1.38 (1.16–1.65) Wealth index Poorest 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Poorer 1.39 (1.18–1.63) 1.36 (1.15–1.60) 2.02 (1.67–2.45) 1.55 (1.13–2.13) 1.22 (0.95–1.56) 0.82 (0.61–1.10) 1.27 (1.01–1.60) 1.06 (0.83–1.34) Middle 1.86 (1.58–2.20) 1.78 (1.51–2.11) 2.97 (2.38–3.72) 2.36 (1.63–3.43) 0.95 (0.72–1.25) 0.91 (0.67–1.22) 1.40 (1.11–1.76) 1.19 (0.94–1.51) Richer 2.64 (2.19–3.17) 2.62 (2.15–3.20) 7.36 (5.31–10.18) 7.14 (4.08–12.49) 1.06 (0.76–1.48) 0.86 (0.61–1.23) 1.48 (1.16–1.87) 1.10 (0.85–1.43) Richest 5.19 (3.96–6.80) 3.71 (2.78–4.94) 13.04 (7.10–23.95) 21.63 (7.30–64.08) 1.67 (1.09–1.60) 1.16 (0.79–1.70) 2.07 (1.59–2.71) 1.14 (0.85–1.54) Parity 1–4 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 > 4 0.71 (0.61–0.82) 0.93 (0.84–1.04) 0.59 (0.48–0.72) 0.78 (0.58–1.04) 1.01 (0.84–1.21) 1.03 (0.84–1.25) 1.48 (1.27–1.71) 1.06 (0.94–1.21) Women decision making power Low 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Moderate 1.04 (0.91–1.19) 1.02 (0.86–1.21) 0.91 (0.74–1.12) 0.96 (0.70–1.31) 0.97 (0.74–1.27) 0.76 (0.55–1.06) 1.26 (1.10–1.44) 0.97 (0.81–1.18) High 1.22 (1.01–1.47) 1.47 (1.03–2.10) 1.12 (0.77–1.63) 1.04 (0.85–1.27) Currently working 1.10 (0.94–1.28) 1.71 (1.49–1.95) 0.69 (0.55–0.86) 2.52 (1.51–4.22) 1.09 (0.78–1.53) 0.87 (0.71–1.07) 0.97 (0.87–1.08) 1.37 (1.21–1.56) Sex of household head Male 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Female 1.11 (0.92–1.33) 1.09 (0.92–1.30) 1.58 (1.18–2.11) 2.04 (1.14–3.67) 1.11 (0.82–1.51) 1.02 (0.75–1.37) 1.13 (1.00–1.26) 1.12 (0.98–1.28) N.B. Numbers represent odds ratios. Ref = reference category Yaya et al. BMC Pregnancy and Childbirth (2018) 18:194 Page 8 of 9 services [10]. Again, religious beliefs and residency usu- The Benin government needs to create strategies that ally indicate cultural background and influence norms, cover both the supply and demand side interventions, values and beliefs in relation to women’s status, service specifically to reach the uneducated, living in remote areas use and childbirth. Previous studies have reported low with inadequate resources to have access to health care levels of maternal healthcare utilization among ethnic services. Such strategy must go beyond any specific inter- minority women in rural areas [32–34]. Also, maternal vention for maternal health care to accommodate a wider decision-making power was associated with health care developmental agenda and human capital development. behaviors. Women’s empowerment enhance the know- Abbreviations ledge and need of health care and awareness of services ANC: Antenatal care; DHS: Demographic Health Survey; IRB: Institutional which can improve through behavior change communi- Review Board; MMR: Maternal Mortality Ratio; SDGs: Sustainable Development Goals; SSA: Sub-Saharan Africa; TBA: Traditional Birth Attendant; cation and increase the ability of a woman to have posi- USAID: United States Agency for International Development; WHO: World tive health care-seeking behavior. Overall, our study is Health Organization consistent with the findings from a review of numerous Acknowledgments studies in developing countries that women’s empower- The authors thank the MEASURE DHS project for their support and for free ment is positively associated with the use of maternal access to the original data. health care services [35]. Funding The authors have no support or funding to report. Strengths and limitations The main strength of this study is that it leverages on Availability of data and materials nationally representative data collected through a consist- Data for this study were sourced from Benin Demographic and Health surveys (DHS) and available here: https://dhsprogram.com/what-we-do/ ent methodology in 2006 and 2011–12. In addition, this is survey/survey-display-420.cfm and here: https://dhsprogram.com/what-we- the foremost nationwide analyses that explores antenatal do/survey/survey-display-491.cfm visits, facility-based delivery, postnatal and contraceptive Authors’ contributions utilization in Benin, and as such could serve as benchmark SY and ME contributed to the study design, the review of literature, and and stimulus for further nationwide studies on related analysis of literature, manuscript conceptualisation and preparation. OU, AA subjects. Nonetheless, cross sectional data are unable to and GB critically reviewed the manuscript for its intellectual content. SY had final responsibility to submit for publication. All authors read and approved sufficiently establish causality, again due to self-report the final manuscript. method of eliciting information from respondents, there could be possibility of recall bias which could affect the Ethics approval and consent to participate Ethics approval for this study was not required since the data is secondary level of utilization of maternal health care services re- and is available in the public domain. More details regarding DHS data and ported in this study. ethical standards are available at: http://goo.gl/ny8T6X. Conclusion Consent for publication No consent to publish was needed for this study as we did not use any This study has identified the importance of vital maternal details, images or videos related to individual participants. In addition data care services and associated socio-demographic, economic used is available in the public domain. and proximate factors disparities against the backdrop of Competing interests poor maternal health indicators in Benin. The findings The authors declare that they have no competing interests. showed consistent differentials in the use of key maternal health services, such as ANC visits, facility-based delivery, Publisher’sNote postnatal care and contraceptive use, in favor of women in Springer Nature remains neutral with regard to jurisdictional claims in urban, educated, high economic status and use of media. published maps and institutional affiliations. Though the study revealed disparities in selected determi- Author details nants of maternal care services in Benin, however, there School of International Development and Global Studies, University of are other factors such as environmental conditions, gov- Ottawa, Ottawa, Canada. Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, ernance, culture, infrastructure and availability of medical University of Warwick, Coventry CV4 7AL, UK. Bloomberg School of Public equipment and personnel that play vital role in reduction Health, Johns Hopkins University, Baltimore, MD, USA. Department of of these differences. Hence, the findings would guide Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria. stakeholders in health care system to address the unequal access in health care services. As we strive for universal Received: 14 February 2018 Accepted: 23 May 2018 health coverage, health care interventions, programmes and policies should be strengthened to enhance maternal References care services utilization, and tackle the disparities in the 1. Yaya S, Bishwajit G, Shah V. 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BMC Pregnancy and ChildbirthSpringer Journals

Published: May 31, 2018

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