Examining trends in inequality in the use of reproductive health care services in Ghana and Nigeria

Wealth-related inequalities in the utilisation of modern contraceptives in Papua New Guinea: evidence from the 2016-2018 Demographic and Health Survey data

OBJECTIVE

To examine the wealth-related disparities in modern contraceptives use among women in Papua New Guinea.

DESIGN

We performed a cross-sectional analysis of the 2016-2018 Papua New Guinea Demographic and Health Survey data. We included 11 618 women of reproductive age in our final analysis. Percentages were used to present the results on utilisation of modern contraceptives. A concentration curve was used to summarise the cumulative use of modern contraceptives by wealth index (ranked into groups: richest, richer, middle, poorer and poorest). We used a decomposition analysis to estimate the contributions of individual factors towards wealth-related inequality in modern contraceptives use. We estimated the slope index of inequality (SII) and the relative index of inequality (RII) in modern contraceptive utilisation to provide summary evidence of inequality.

SETTING

Papua New Guinea.

PARTICIPANTS

Women aged 15-49 years.

OUTCOME MEASURE

Modern contraceptives utilisation.

RESULTS

Overall, 27.5% of Papua New Guinea women used modern contraceptives. The concentration curve showed that the use of modern contraceptives was highly concentrated among women of the richest household wealth index as the concentration curve lies below the equality line. The SII (0.210, CI 0.182 to 0.239) indicates that the richest group uses more modern contraceptives. The RII depicts a relative difference of 2.044 between the richest and the poorest women in the use of modern contraceptives.

CONCLUSIONS

Our study has shown that modern contraceptives use among women in Papua New Guinea is low. Women from the richest household wealth index group had the highest propensity to use modern contraceptives in comparison with those from poorer homes. The Ministry of Health and other organisations must design and carry out initiatives aimed at enhancing the availability of and use of modern contraceptives among women from less affluent backgrounds.

Marginalization and women's healthcare in Ghana: Incorporating colonial origins, unveiling women's knowledge, and empowering voices

The origins of marginalization in nursing and the health sector in Ghana can be traced to colonialism and how a colonial era laid a solid foundation for inequities and entrenched disparities, as well as the subsequent normalization of marginalizing acts, in the health sector, particularly for women. Drawing upon varied literature over a 60-year period and perspectives from feminist theory, this paper considers the lasting impact of Ghanaian women's historical position during the colonial era and within the patriarchal system that ensued. Through this process, it becomes possible to shed light on the crucial role that colonialism has played in women's experiences, perspectives, and health-seeking behaviors, and the manner in which it has created a healthcare sector that marginalizes women's health. Although women possess valuable knowledge which should be an asset to consider when providing healthcare services, marginalization of that knowledge has become normalized across society and the healthcare system. There is an urgent need to disrupt and challenge this normalization, and to advocate empowerment and recognition of women's valuable knowledge and experiences, providing women a voice in health decision-making discourses and in the research processes by which we understand and develop healthcare. Through this, healthcare in Ghana could become more empowering, inclusive, and responsive to the unique experiences and needs of Ghanaian women. By understanding something of the historical origins of women's health marginalization within colonialism, nurses can begin to appreciate women's knowledge and integrate it into healthcare strategies that are more gender-sensitive and equitable.

Factors Associated with Utilization of Sexual and Reproductive Health Services among Married Adolescent Girls in Kano, Northern Nigeria

Background and Objective

Married adolescents face significant obstacles in making informed reproductive health decisions and accessing sexual and reproductive health (SRH) services. It is important to identify barriers hindering these adolescents from accessing SRH services. The aim of this study was to identify factors associated with the utilization of SRH services among married adolescent girls in northern Nigeria.

Methods

We used a cross-sectional study design. The study population comprised of married female adolescents aged 14-19 years who were residents in the study areas for at least six months. The outcome measure was SRH service utilization, defined as the use of any of the conventional SRH services (ante/postnatal care, human immunodeficiency virus (HIV) testing and counseling, sexually transmitted infections (STI) treatment, family planning, and post-abortion care). Predictor variables included the sociodemographic, obstetric, and gynecological characteristics of the respondents. An adapted, pretested, interviewer-administered, and semi-structured questionnaire was employed for data collection. Multivariable logistic regression was used to explore the independent association between selected variables and utilization of SRH services.

Results

A total of 200 respondents were surveyed (100 each from an urban and a rural community in Kano, Nigeria), survey response rate: 94.5%. The age of respondents ranged from 14 to 19 years, with mean age (± standard deviation) of 18.5 (±1.1) years and 17.5 (±1.3) years for urban and rural respondents, respectively. All respondents were aware of the available SRH facilities and preferred public facilities (92.6% urban respondents and 67.0% rural respondents). Ever-use of SRH services was higher among urban than rural respondents (86% vs. 56%, respectively). Geographic proximity was a key factor for urban respondents (64.2%), while affordability was considered important by rural respondents (47.9%). Respondent's age and partner's occupation were independently associated with utilization of SRH services. Urban respondents whose husbands were businessmen were seven times more likely to use SRH services than those whose partners were civil servants (adjusted odds ratio [aOR] = 6.80, 95% confidence interval [CI]: 1.29-35.84, P = 0.02). Rural respondents 18 years of age and older were approximately six times more likely to utilize SRH services than those <18 years (aOR = 5.71, 95% CI: 1.56-12.78, P = 0.01).

Conclusion and Global Health Implications

Awareness of available SRH services was high in the study population, and service utilization was influenced by the respondent's age and partner's occupation. Findings from this study can help inform the development of age-appropriate and accessible SRH services tailored to married adolescents in similar settings.

Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?

BACKGROUND

Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage.

METHODS

Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices.

RESULTS

Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes.

CONCLUSIONS

Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.

Household Poverty-Wealth and Decision-Making Autonomy as Predictors of Reproductive and Maternal Health Services Utilization among Rural Women in Nigeria: Evidence from a National Survey

Background

Adequate reproductive and maternal healthcare services utilization are significant in reducing maternal deaths, however, the prevalence rate of contraceptive use remains low, with inadequate maternal health services utilization among rural women in Nigeria. This study examined the influence of household poverty-wealth and decision-making autonomy on reproductive and maternal health services utilization among rural women in Nigeria.

Methods

The study analyzed data from a weighted sample of 13,151 currently married and cohabiting rural women. Descriptive and analytical statistics including multivariate binary logistic regression were conducted using Stata software.

Results

An overwhelming majority of rural women (90.8%) have not used modern contraceptive methods, with poor utilization of maternal health services. About 25% who delivered at home received skilled postnatal checks during the first 2 days after childbirth. Household poverty-wealth significantly reduced the likelihood of using modern contraceptives (aOR: 0.66, 95% CI: 0.52-0.84), having at least four ANC visits (aOR: 0.43, 95% CI: 0.36-0.51), delivering in a health facility (aOR: 0.35, 95% CI: 0.29-0.42) and receiving a skilled postnatal check (aOR: 0.36, 95% CI: 0.15-0.88). Women's decision-making autonomy regarding their healthcare significantly increased the use of modern contraceptives and the number of ANC visits, while women's autonomy on how their earnings are spent positively influenced the use of maternal healthcare services.

Conclusions

In conclusion, the use of reproductive and maternal health services among rural women was associated with household poverty-wealth and decision-making autonomy. Government should formulate more pragmatic policies that will create awareness and promote universal access to reproductive and maternal healthcare services.

Wealth inequalities in reproductive and child health preventive care in Mozambique: a decomposition analysis

Background

Assessing the gap between rich and poor is important to monitor inequalities in health. Identifying the contribution to that gap can help policymakers to develop interventions towards decreasing that difference.

Objective

To quantify the wealth inequalities in health preventive measures (bed net use, vaccination, and contraceptive use) to determine the demographic and socioeconomic contribution factors to that inequality using a decomposition analysis.

Methods

Data from the 2015 Immunisation, Malaria and AIDs Indicators Survey were used. The total sample included 6946 women aged 15–49 years. Outcomes were use of insecticide-treated nets (ITN), child vaccination, and modern contraception use. Wealth Index was the exposure variable and age, marital status, place of residence, region, education, occupation, and household wealth index were the explanatory variables. Wealth inequalities were assessed using concentration indexes (Cindex). Wagstaff-decomposition analysis was conducted to assess the determinants of the wealth inequality.

Results

The Cindex was −0.081 for non-ITN, −0.189 for lack of vaccination coverage and −0.284 for non-contraceptive use, indicating a pro-poor inequality. The results revealed that 88.41% of wealth gap for ITN was explained by socioeconomic factors, with education and wealth playing the largest roles. Lack of full vaccination, socioeconomic factors made the largest contribution, through the wealth variable, whereas geographic factors came next. Finally, the lack of contraceptive use, socioeconomic factors were the main explanatory factors, but to a lesser degree than the other two outcomes, with wealth and education contributing most to explaining the gap.

Conclusion

There was a pro-poor inequality in reproductive and child preventive measures in Mozambique. The greater part of this inequality could be attributed to wealth, education, and residence in rural areas. Resources should be channeled into poor and non-educated rural communities to tackle these persistent inequities in preventive care.

Geospatial distribution and bypassing health facilities among National Health Insurance Scheme enrollees: implications for universal health coverage in Nigeria

BACKGROUND

This study was carried out to enable an assessment of geospatial distribution and access to healthcare facilities under the National Health Insurance Scheme (NHIS) of Nigeria. The findings will be useful for efficient planning and equitable distribution of healthcare resources.

METHODS

Data, including the distribution of selected health facilities, were collected in Ibadan, Nigeria. The location of all facilities was recorded using Global Positioning System and was subsequently mapped using ArcGIS software to produce spider-web diagrams displaying the spatial distribution of all health facilities.

RESULTS

The result of clustering analysis of health facilities shows that there is a statistically significant hotspot of health facility at 99% confidence located around the urban areas of Ibadan. The significant hotspot result is dominated by a feature with a high value and is surrounded by other features also with high values. Away from the urban built-up area of Ibadan, health facility clustering is not statistically significant. There was also a high level (94%) of bypassing of NHIS-accredited facilities among the enrollees.

CONCLUSIONS

Lopsided distribution of health facilities in the study area should be corrected as this may result in inequity of access to available health services.

Determinants of Utilization of Institutional Delivery Services in Zambia: An Analytical Cross-Sectional Study

Institutional delivery at birth is an important indicator of improvements in maternal health, which remains one of the targets of sustainable development goals intended to reduce the maternal mortality ratio. The purpose of the present study was to identify the determinants of utilization of institutional delivery in Zambia. A population-based cross-sectional study design was used to examine 9841 women aged 15–49 years from the 2018 Zambia Demographic and Health Survey. A multiple logistic regression was applied to calculate odds ratios (ORs) with 95% confidence intervals (CIs) to identify determinants of utilization of institutional delivery. Sociodemographic factors were significantly associated with institutional delivery: woman’s (OR: 1.76; 95% CI: 1.04–2.99) and husband’s (OR: 1.83; 95% CI: 1.09–3.05) secondary/higher education, higher wealth index (OR: 2.31; 95% CI: 1.27–4.22), and rural place of residence (OR: 0.55; 95% CI: 0.30–0.98). Healthcare-related factors were also significantly associated with institutional delivery: 5–12 visits to antenatal care (OR: 2.33; 95% CI: 1.66–3.26) and measuring blood pressure (OR: 2.15; 95% CI: 1.32–2.66) during pregnancy. To improve institutional delivery and reduce maternal and newborn mortality, policymakers and public health planners should design an effective intervention program targeting these factors.

Noncompliance with the WHO's Recommended Eight Antenatal Care Visits among Pregnant Women in Sub-Saharan Africa: A Multilevel Analysis

BACKGROUND

In 2016, the World Health Organization (WHO) introduced a minimum of eight antenatal care (ANC) visits for positive pregnancy outcomes. This study examined the prevalence of noncompliance with 8+ ANCvisits and its associated factors in sub-Saharan Africa (SSA).

METHODS

We used data from the Demographic and Health Surveys of eight countries in SSA. A pooled sample of 63,266 pregnant women aged 15-49 years who had given birth to children within 5 years prior to the surveys was included in this study. To examine the factors associated with noncompliance with ANC 8+ visits, multilevel binary logistic regression analysis was conducted, and the results were reported using odds radios at 95% confidence interval (CI).

RESULTS

The pooled prevalence of noncompliance with ANC 8+ visits was 92.3% (95% CI: 91.1%-93.3%) with the highest and lowest prevalence in Zambia (98.7%, 95% CI: 98.3%-99.1%) and Libya (73.4%, 95% CI: 70.4%-76.2%), respectively. With the individual level factors, women's age (44-49 years-aOR = 0.33, 9% CI: 0.14-0.78), health insurance registration, (yes-aOR = 0.53, 95% CI: 0.29-0.98), and economic status (richest-aOR = 0.16, 95% CI: 0.05-0.49) were negatively associated with noncompliance with 8+ ANC visits, while parity (five or more children-aOR = 1.68, 95% CI: 1.12-2.52) was positively associated with noncompliance with 8+ ANC visit. With the community level factors, community level literacy was negatively associated with noncompliance with 8+ ANC visit (high-aOR = 0.56, 95% CI: 0.32-0.99).

CONCLUSION

About eight out of ten pregnant women did not comply with the WHO's recommended minimum of eight ANC visits for positive pregnancy outcomes in SSA. Empowering the economic status of women , enhancing health insurance and education coverage, and giving more attention to young pregnant women and those with more children are crucial for improving the coverage of ANC 8+ visits in the region.

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

Twenty-five years ago, the International Conference on Population and Development highlighted the need to address sexual and reproductive health (SRH) rights on a global scale. The sub-Saharan Africa region continues to have the highest levels of maternal mortality and HIV, primarily affecting the most vulnerable populations. Recognising the critical role of policy in understanding population health, we conducted a systematic review of original primary research which examined the relationships between equity-focused legislation and policy and the utilisation of SRH services by vulnerable populations in sub-Saharan Africa. We searched nine bibliographic databases for relevant articles published between 1994 and 2019. Thirty-two studies, conducted in 14 sub-Saharan African countries, met the inclusion criteria. They focused on maternal health service utilisation, either through specific fee reduction/removal policies, or through healthcare reforms and insurance schemes to increase SRH service utilisation. Findings across most of the studies showed that health-related legislation and policy promoted an increase in service utilisation, over time, especially for antenatal care, skilled birth attendance and facility-based delivery. However, social health inequalities persisted among subgroups of women. Neither the reviewed studies nor the policies specifically addressed youth, people living with HIV and people with disabilities. In the era of the sustainable development goals, addressing health inequities in the context of social determinants of health becomes unavoidable. Systematic and rigorous quantitative and qualitative research, including longitudinal policy evaluation, is required to understand the complex relationships between policy addressing upstream social determinants of health and health service utilisation.

Patterns and Predictors of Insufficient Antenatal Care Utilization in Nigeria over a Decade: A Pooled Data Analysis Using Demographic and Health Surveys

This study investigated the patterns of antenatal care (ANC) utilization and insufficient use of ANC as well as its association with some proximate socio-demographic factors. This was a cross-sectional study using pooled data Nigeria Demographic and Health Surveys from years 2008, 2013 and 2018. Participants were 52,654 women of reproductive age who reported at least one birth in the five years preceding the surveys. The outcome variables were late attendance, first contact after first trimester and less than four antenatal visits using multivariable logistic regression analysis. The overall prevalence of late timing was 74.8% and that of insufficient ANC visits was 46.7%. In the multivariable regression analysis; type of residency, geo-political region, educational level, household size, use of contraceptives, distance to health service, exposure to the media and total number of children were found to be significantly associated with both late and insufficient ANC attendance. About half of the pregnant women failed to meet the recommendation of four ANC visits. Investing on programs to improve women's socio-economic status, addressing the inequities between urban and rural areas of Nigeria in regard to service utilization, and controlling higher fertility rates may facilitate the promotion of ANC service utilization in Nigeria.

Factors influencing the use of modern contraceptive in Nigeria: a multilevel logistic analysis using linked data from performance monitoring and accountability 2020

Background

The population of Nigeria is estimated at over 190 million and it is projected to increase by 44% between 2015 and 2030. However, less than one-quarter of women within reproductive age in Nigeria uses modern contraceptive methods despite its importance. Hence, this study aims at examining the influence of individual and community level factors on the use of modern contraceptive method.

Methods

The study is a secondary analysis of linked household and Service Delivery Point datasets from a 2018 survey conducted by Performance, Monitoring and Accountability in Nigeria. Data was abstracted for a total of 9126 sexually active women within the ages of 15–49 years across 295 enumeration areas in seven States. A 2-level binary logistic regression was used to examine the association between study variables and the use of modern contraceptives while adjusting for the clustering effect.

Results

There was significant influence of educational level, marital status, parity, socio-economic status, fertility intention, and awareness of family planning methods on the use of modern contraceptives. Also, women who perceived support from someone in the community on family planning were more likely to use modern contraceptive unlike those without such support. Those who believed that contraceptive methods are used by almost all and some of their friends or relatives were more likely to use modern contraceptive compared to those who think otherwise.

Conclusions

The study shows the need to reduce inequalities between FP utilization across women with different socio-economic status as well as increasing the awareness for modern contraceptive methods.

Inequalities in reproductive health care use in five West-African countries: A decomposition analysis of the wealth-based gaps

BACKGROUND

Family planning and maternal care services have become increasingly available in West Africa but the level of non-use remains high. This unfavorable outcome may be partly due to the unaffordability of reproductive health care services.

METHODS

Using the Demographic Health Survey data from Burkina Faso, Niger, Nigeria, Ghana, and Senegal, we perform a decomposition analysis to quantify the contribution of socio-demographic characteristics to disparities in exposure to mass media information on family planning, use of modern contraceptives, adequate antenatal care visits, facility-based childbirth and C-section between low-wealth and high-wealth women.

RESULTS

Our study shows that differences in maternal characteristics between the wealth groups explain at least 40% of the gap in exposure to mass media family planning information, 30% in modern contraceptive use, 24% of adequate antenatal care visits, 47% of the difference in facility-based childbirths, and 62% in C-section. Lack of information on pregnancy complications, living in rural residence, religion, lack of autonomy in health facility seeking decision, need to pay, and distance explains the disparity in reproductive health care use across all countries. In countries with complete fee exemption policies for specific groups in the population, Ghana, Niger, and Senegal, the inequality gaps between wealth groups in having an adequate number of antenatal care visits and facility-based childbirth are smaller than in countries with partial or no exemption policies. But this is not the case for C-section.

CONCLUSIONS

There is evidence that current policies addressing the cost of maternal care services may increase the wealth-based inequality in maternal care use if socio-demographic differences are not addressed. Public health interventions are needed to target socio-demographic disparities and health facility seeking problems that disadvantage women in poor households.

Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study

OBJECTIVE

Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania.

DESIGN

Observational retrospective study.

SETTING

St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania.

PARTICIPANTS

3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015.

RESULTS

The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%).

CONCLUSION

We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions.