Determinants of use of maternal health services in Nigeria--looking beyond individual and household factors

Intergenerational differences in antenatal care and supervised deliveries in Nigeria

OBJECTIVE

To assess whether age cohort influences the likelihood of receiving antenatal care (ANC) and having a supervised delivery, before and after adjusting for other factors.

DESIGN

Using data from the 2008 Nigeria Demographic and Health Survey, we grouped women into three distinct cohorts based on their year of birth: the young (1984-1993), the middle (1974-1983) and the older (1959-1973) cohorts. We applied multilevel logistic regression methods to assess the influence of age cohort on receiving ANC and having a supervised delivery among women (n=18,028) whose most recent birth occurred anytime in the five years preceding the survey.

RESULTS

We identified belonging to the youngest age cohort, rural residence, lack of schooling, higher parity, residence in northern region and poor economic status as determinants of low uptake of ANC and supervised deliveries.

CONCLUSION

Urgent efforts are needed in Nigeria to ensure that young women in particular receive ANC and have supervised deliveries. An agenda promoting a combination of individuals campaigning for change (particularly in northern Nigeria), communities raising awareness among men and women, and governmental and nongovernmental organizations working together to find practical solutions is an indispensable aim for saving the lives of many women and children who are at risk of dying of maternal and child-related diseases.

Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso

OBJECTIVE

To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees.

METHODS

The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility).

RESULTS

76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility.

CONCLUSIONS

User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Inequalities in under-5 mortality in Nigeria: do ethnicity and socioeconomic position matter?

BACKGROUND

Each ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria.

METHODS

Using multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities.

RESULTS

The prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care.

CONCLUSIONS

Ethnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities.

Inequities in utilization of maternal health interventions in Namibia: implications for progress towards MDG 5 targets

BACKGROUND

Inequities in the utilization of maternal health services impede progress towards the MDG 5 target of reducing the maternal mortality ratio by three quarters, between 1990 and 2015. In Namibia, despite increasing investments in the health sector, the maternal mortality ratio has increased from 271 per 100,000 live births in the period 1991-2000 to 449 per 100,000 live births in 1998-2007. Monitoring equity in the use of maternal health services is important to target scarce resources to those with more need and expedite the progress towards the MDG 5 target. The objective of this study is to measure socio-economic inequalities in access to maternal health services and propose recommendations relevant for policy and planning.

METHODS

Data from the Namibia Demographic and Health Survey 2006-07 are analyzed for inequities in the utilization of maternal health. In measuring the inequities, rate-ratios, concentration curves and concentration indices are used.

RESULTS

Regions with relatively high human development index have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. The rich use the public health facilities 30% more than the poor for child delivery.

CONCLUSION

Most of the indicators such as delivery by trained health providers, delivery by caesarean section and postnatal care show inequities favoring the most educated, urban areas, regions with high human development indices and the wealthy. In the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realize the MDG 5 targets so long as a large segment of society has inadequate access to essential maternal health services and other basic social services. Addressing inequities in access to maternal health services should not only be seen as a health systems issue. The social determinants of health have to be tackled through multi-sectoral approaches in line with the principles of Primary Health Care and the recommendations of the Commission on Social Determinants of Health.