Determinants of antenatal care and skilled birth attendance services utilization among childbearing women in Guinea: evidence from the 2018 Guinea Demographic and Health Survey data

This study sought to assess ANC and SBA and its associated factors among childbearing women in Guinea. The study results revealed a direct association between increasing levels of education and utilisation of both ANC and SBA services. Specifically, women who had at least secondary level of education and those whose partners had at least secondary level of education showed higher probability of using both ANC and SBA services, relative to their counterparts with lower levels of education. Previous studies in developing countries such as Ethiopia [18, 10] and Lao [19]also found a strong association between couple’s level of education and ANC utilisation. Similar studies in Ethiopia [20‐22], Guinea-Bissau [23], Nigeria [24], and northern parts of Ghana [25] revealed educational attainment as a predictor of utilization of SBA services. Generally, attainment of higher education has been noted as a strong predictor of maternal healthcare utilization [16, 26, 27]. Mezmur et al. [22] and Gebresilassie et al. [28] noted that higher education exposes women to knowledge on health issues which may positively influence their uptake of maternal healthcare services. Empirical evidence shows that educated women are more receptive to new health-promoting ideas which reinforce the demand side of health [29]. Women’s education develops literacy, which in turn is connected to an array of positive health outcomes because of “health literacy”, theorized as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” [30]. This educational attainment heightens women’s aptitude to identify sickness symptoms, use prevention services and better self-management of disease and the need to seek appropriate health care [31]. Significantly, women’s education bridges the somewhat traditional power distance between them and their male counterparts, especially in patriarchal sub-Saharan African societies by facilitating their empowerment, and thus, considerable decision-making power at the household and community level [32]. According to some researchers [33‐35], women are capable or have greater autonomy to make constructive decisions about their own and that of their children’s health when well educated. For example, less empowered women in north-eastern Ghana were unable to choose a delivery place, decide on childcare health issues and even their own dietary needs [36]. Higher education makes women more confident and gives them the ability to take wise health decisions [20]. The other finding that women’s partners’ educational attainment strongly predicts maternal healthcare utilization highlights the significant roles men play in their partners’ health decision-making [25]. Thus, partner’s education may play similar supporting roles toward women’s access to ANC and SBA services. For example, some studies have emphasized that male involvement in women’s health needs promotes their maternal and reproductive healthcare choices and utilization [37‐41]. Prakash, Swain, and Negi [42] noted that when husbands recognize the significance of women’s healthcare needs, related decisions are urgently addressed.

The study also identified wealth status as a predictor of utilization of both ANC and SBA services. Women within the richest wealth quintile specifically had higher propensity of utilizing maternal healthcare services, compared to their counterparts from the poorest wealth quintile, a finding that is consistent with previous studies in other countries [16, 17]. Some studies have specifically found higher likelihood of utilization of ANC services among women in the richest wealth quantile [43, 18, 10, 44], with similar observations on SBA utilization [21, 22, 27, 45]. In Guinea, the main reason for the low likelihood of maternal healthcare utilization among women from poorer households could not be the cost associated with healthcare. This is because the Ministry of Health of Guinea has since 2010 provided free obstetric care services, including antenatal care and health facility delivery [46]. However, despite the availability of free maternal healthcare services in Guinea, women from poor homes are likely to face other barriers, such as cost of transportation, which may obstruct their uptake of ANC and SBA services. For poor households, priority may probably be given to basic daily needs instead of healthcare expenses because of lack of adequate financial resources [47, 48]. Wealthier women, on the other hand, will certainly not face these barriers, as they have money to pay for the maternal healthcare services, even if they were costly, and can also take care of other financial obligations which could prevent poorer women from accessing maternal healthcare services. Appropriate service delivery methods that include local community-based interventions that target vulnerable poor women groups are required [49].

Religion and intention of pregnancy as strong predictors of maternal healthcare services utilization among women in Guinea were also noted. Specifically, the study showed a significant association between being a Muslim woman and a Christian woman and uptake of ANC and SBA services respectively. This finding corroborates other findings in some previous studies in northern Ghana [25, 50] and rural Nigeria [24] which revealed an association between Christianity and SBA uptake. Conversely, this finding contradicts other findings [22] that did not find religion as a predictor of SBA uptake. Although no clear explanation can be attributed to this pattern in the current findings, we speculate that quite a number Muslim women are betrothed to very influential Muslim men at younger adult age so are more compelled to seek ANC because they lack personal experience related to maternal practices. However, when these Muslim women are due for delivery, strong religio-cultural norms allow these women to deliver at homes through the help of untrained traditional birth attendants through spousal and extended family endorsement. Such indigenous maternal practices are minimal with Christian women, though may exist. Despite this finding, there is the need for future qualitative research to understand more about the role of religion in maternal healthcare utilization. There is the need to formulate and disseminate particular culturally appropriate messages targeting women and families based on their religions and offer home-based care to those who have challenges using ANC and SBA. These interventions can be complemented with community-based interventions that focus more on awareness creation that could help modify some cultural practices that might have outlived their usefulness, especially among less educated and those with low socioeconomic status[49].

Similar to previous research [51, 52], women with intended pregnancies were more likely to patronize ANC and SBA services, compared with their counterparts with unintended pregnancies. This finding confirms the findings of Dutamo et al. [51] and Tesfaye et al. [52] while the link between unintended pregnancy and low uptake of maternal healthcare services seems unclear, some researchers have speculated some reasons for this association. Parkhurst et al. [53], for instance, indicated that this association could be suggestive of women’s inability to control issues related to both their reproductive health and household resources. Tesfaye et al. [52] also noted that women who unintentionally get pregnant may consider having abortion, which prevents their subsequent use of maternal healthcare services. Alternatively, women with unwanted pregnancies might be reluctant to seek ANC and SBA services.

Healthcare decision-making also strongly predicted uptake of maternal healthcare services. Specifically, women who take healthcare decisions alone were more probable to use ANC and SBA services compared to those who do not take healthcare decisions alone. This finding is consistent with the findings of Ousman et al. [18] who found women’s decision making capacity as a strong predictor of ANC uptake in Ethiopia. Similarly, Ameyaw et al. [54] noted that women’s autonomy in making healthcare decisions positively affect uptake of SBA services in Ghana. This finding suggests that women’s ability to make decisions concerning their health could positively affect their uptake of maternal healthcare services. Despite our finding that partners’ education plays a role in women’s healthcare decisions and thus in their utilization of ANC and SBA, the finding that women who take healthcare decisions alone were more probable to use ANC and SBA services compared to those who do not take healthcare decisions alone is an indication that the level of education of the partner may not always have an influence on a woman’s autonomy but rather her own education.

Besides, women who listen to radio less than once a week have higher probability of using ANC services and that those who watch television less than once a week are more likely to use SBA services than those who do not watch television or read newspaper at all. Some previous studies [55, 56, 18, 57] suggest that radio, television, and newspaper could be channels through which health information reach women. Therefore, women who use such media easily get access to information on the importance of maternal healthcare services, which could influence them to use maternal healthcare services such as ANC and SBA [58]. Zamawe et al. [59] revealed how mass media campaign positively affected the use of health services including ANC, in Malawi. Hence, women exposed to media are more likely to have more information, knowledge, positive attitudes and may value the importance of ANC and SBA services by utilizing them. Residential variation in the utilization of SBA services in Guinea was also established in the current study. Context-specific factors such as lack of competent personnel, quality services as well as varied socio-cultural norms and poor socio-economic status of women may restrict SBA utilization in the rural setting compared to their urban counterparts. For example, limited availability of transport, traveling longer distances to access health care facilities, and the cost of maternal services may serve as barriers for rural women [60, 61]. A comprehensive community-level interventions that consider residential homogeneity regarding infrastructure (e.g., health facilities, roads) and socioeconomic empowerment (e.g., educational and vocational training) could boost women health-promoting behaviours and their access to maternity healthcare services.