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

Data for this study were derived from two rounds of Demographic and Health Survey in Benin that provided information on antenatal care, institutional delivery and contraceptive use. The datasets have one record for every eligible woman as defined by the household schedule. The questionnaire contains all the data collected from the individual woman for whom information on antenatal care, delivery and contraceptive usage and some variables from the household were elicited. The 2006 and 2012 Benin Demographic and Health Survey (BDHS) data contains 17,794 and 16,599 cases (units of analysis), which in this file is the woman. BDHS performed cross-sectional analyses using nationally representative data, to collect information on demographic, health, and nutrition indicators. The survey is majorly funded by the United States Agency for International Development (USAID). The two rounds of BDHS utilized a multi-stage, stratified sampling design, with households as the sampling unit. Within each sample household, all eligible women were interviewed [20].

In this study, we used four outcome measures of maternal health care utilization extracted from the BDHS. Firstly, we derived the; “number of antenatal care (ANC) visits during pregnancy”, this was grouped as 4 or more ANC visits vs below 4 ANC visits. ANC visits is a measure of skilled pregnancy care received by women during most recent pregnancy. Secondly, we extracted the “place of delivery (home vs health facility)”. This was measured as a binary outcome for 1, if a woman delivered in a health facility (where skilled delivery attention is available) and 0, if otherwise. In addition, postnatal care was measured by “respondents health’s checked after discharge/delivery at home” Lastly, women’s “contraceptive use”; was obtained as binary indicator taking 1 if the “woman ever used a contraceptive method” and 0, if otherwise.

The utilization of ANC visits, facility-based delivery and contraceptive use are known to depend on a set of determinants, such as demographic, economic, other proximate and social factors. Empirical literature on the factors pertinent to maternal health care services basically helped to select the variables of study. These variables age of individual woman (15–19, 20–24, 25–29, 30–34, 35–39, 40–44 and 45–49 year), geographical region (Alibori, Atacora, Atlantique, Borgou, Collines, Couffo, Donga, Littoral, Mono, Queme, Plateau and Zou), type of residence (rural vs urban). Educational attainment was categorized as those having no formal education, primary, secondary and higher education. Religious beliefs included; Christianity, Islam, traditional and other religion, while access to health information was measured using frequency of reading newspaper or magazine, listening to radio and watching TV. The wealth scores is obtained by principal components analysis, based on a list of household assets as specified by DHS, which include, number of household members, wall and roof materials, floor types, access to potable water and sanitation, type of cooking fuel, ownership of television, radio, motorcycle, refrigerator amongst others. Based on the weighted wealth scores, households were grouped into five wealth quintiles; poorest, poorer, middle, richer and richest. Furthermore, parity was measured by the number of children ever born by each individual woman; categorized as 1–4 and > 4 children.

We did the analyses using publicly available data from demographic health surveys. Ethical procedures were the responsibility of the institutions that commissioned, funded, or managed the surveys. All DHS surveys are approved by ICF international as well as an Institutional Review Board (IRB) in respective country to ensure that the protocols are in compliance with the U.S. Department of Health and Human Services regulations for the protection of human subjects.

Summary statistics including percentage and means (±standard deviation) were used to examine the distribution of socio-demographic, economic distal and proximate maternal characteristics. To adjust for data representation, we used complex survey module (svyset) for all analyses to account for clustering, stratification and sample weight. In addition, the percentages of outcome variables were presented in bar chart. The factors associated with ANC visits, facility-based delivery, postnatal care and contraceptive use were examined using logistic regression models. The bivariate analysis conducted to examine the factors that were added in the multivariable regression models involved a simple regression with each explanatory variable. Therefore, factors, which were statistically significant in the crude regression models, were added in the multivariable regression models to adjust for possible confounders. An α level of 0.05 was considered statistically significant. All analyses were conducted using STATA 14.0.

In this study, the characteristics of respondents were explored for 2006 and 2012 respectively. The mean ages of respondents were similar (29.0 ± 9.1/9.0) between the years of survey. The basic socio-demographic characteristics of the respondents were presented in Table 1.

Prevalence of maternal health care utilization.

In this study, four outcomes were measured namely; antenatal care of at least 4 visits, facility-based delivery, postnatal care and utilization of contraceptive methods. The percentage of 4 or more antenatal visits was 61.4% in 2006, and 61.1% in 2012, which showed that there was no increase in the level of antenatal care visits over time. Facility-based delivery was reported as 88.6% in 2006 which had 4.9% increase by 2012. Postnatal care 15.2% in 2006, but increased to 18.4% in 2012. Further, the percentage of contraceptive use was 17.2% in 2006, however reduced to 14% in 2016 (see Fig. 1 for details).

The results showed that women aged 35–49 years had increase in the odds of facility-based delivery, compared to women aged 15–19 years. Further, women aged 45–49 years had 45% significant reduction in the odds of contraceptive use, compared to women aged 15–19 years after adjusting for other covariates (OR = 0.55; 95% CI = 0.33–0.93). Also, geographical region was significantly associated with ANC visits, facility-based, postnatal care and contraceptive use. Rural women had 17% reduction in the odds of contraceptive use, compared to the urban women after adjusting for other covariates (OR = 0.83; 95% CI = 0.70–0.98). Educated women were more likely to utilize ANC visits, facility-based and postnatal care, compared to women with no formal education after adjusting for other covariates.

Women with higher wealth index had significant increase in the odds of adequate ANC visits, facility-based delivery and contraceptive use. Number of children ever born was significantly associated with maternal health care services; women who had above 4 children had significant reduction in adequate ANC visits and facility-based delivery respectively, compared to women who had 1–4 children (ANC- OR = 0.71; 95% CI = 0.61–0.82; facility-based delivery- OR = 0.59; 95% CI = 0.48–0.72). Notwithstanding, women who had above 4 children were 1.48 times as likely to have contraceptive use, compared to women who had 1–4 children (OR = 1.48; 95% CI = 1.27–1.71). Women with moderate decision-making power were 1.26 times as likely to have contraceptive use, compared to women with low decision-making power. Also, women from female headed households were 1.58 times more likely to utilize facility-based delivery, compared to women from male headed households (OR = 1.58; 95% CI = 1.18–2.11). See Table 2 for details.

For 2012, women aged 45–49 years had higher odds of facility-based, compared to women aged 15–19 years after adjusting for other covariates. Respondents aged 35–44 years also had increase in the odds of contraceptive use, compared to those aged 15–19 years. The region and religion of respondents was significantly associated with adequate ANC visits, facility-based delivery, postnatal care and contraceptive use. The respondents with high decision-making power were 1.47 times as likely to have facility-based delivery, compared to women with low decision-making power after adjusting for other covariates (OR = 1.47; 95% CI = 1.03–2.10). Further, women who were currently working or employed had higher odds of ANC visits, facility-based delivery and contraceptive use. Women from female headed households were 2.04 times as likely to have facility-based delivery, compared to other counterpart after adjusting for other covariates (OR = 2.04; 95% CI = 1.14–3.67).

This study has become the foremost to explore and examine 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 women of reproductive age were relatively the same in both rounds of survey. The estimates are consistent with literature from other sub-Saharan Africa countries where maternal health care indicators need more improvement [21‐23]. Furthermore, socio-demographic, economic and proximate determinants were the main predictors of maternal healthcare services. Age, geographical region, place of residence, level of education, religious beliefs, use of media, wealth index and parity were significant predictors for the disparity in access to skilled pregnancy care and fertility control [22‐25].

In addition, this study found disparities in the demographic, social, economic and proximate factors associated with the utilization of maternal health care services. The SDGs are known to support reduction in inequalities and ensure health for all populations. In the light of the above, beyond the utilization of maternal health care, also to reach the most disadvantaged group of the women, vis-a-vis the use of maternal care services must be considered to achieve the set goals [26]. The findings in this study showed that women with lower educational level, inaccessibility of the media (newspaper, radio and television), low economic class, rural dwellers amongst others are less likely to utilize maternal healthcare services. This revealed disproportionate share of maternal healthcare services by certain class of people despite of the high demand. The results were in line with previous studies in other countries [27‐30].

Though there are interventions to improve coverage of maternal and child health care services in sub-Saharan Africa, the disparity in access and use by several factors such as place of residence, use of media, geographical region, educational attainment, age of women and wealth quintile amongst others has remained persistently high in the two rounds of data utilized [30, 31]. Explaining differentials in accessing maternal and reproductive care services is a critical issue, because several other contributory factors, including distance, cultural beliefs or practices, health care seeking behavior, affordability and need for services must also be considered [31]. The findings of this study were consistent with previous studies that reported that improvement in economic status was connected to better use of maternal health services [10]. Again, religious beliefs and residency usually indicate cultural background and influence norms, values and beliefs in relation to women’s status, service use and childbirth. Previous studies have reported low levels of maternal healthcare utilization among ethnic minority women in rural areas [32‐34]. Also, maternal decision-making power was associated with health care behaviors. Women’s empowerment enhance the knowledge and need of health care and awareness of services which can improve through behavior change communication and increase the ability of a woman to have positive health care-seeking behavior. Overall, our study is consistent with the findings from a review of numerous studies in developing countries that women’s empowerment is positively associated with the use of maternal health care services [35].

The main strength of this study is that it leverages on nationally representative data collected through a consistent methodology in 2006 and 2011–12. In addition, this is the foremost nationwide analyses that explores antenatal visits, facility-based delivery, postnatal and contraceptive utilization in Benin, and as such could serve as benchmark and stimulus for further nationwide studies on related subjects. Nonetheless, cross sectional data are unable to sufficiently establish causality, again due to self-report method of eliciting information from respondents, there could be possibility of recall bias which could affect the level of utilization of maternal health care services reported in this study.