Elsevier

Social Science & Medicine

Volume 64, Issue 6, March 2007, Pages 1311-1325
Social Science & Medicine

A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: Evidence from Demographic and Health Surveys (DHS)

https://doi.org/10.1016/j.socscimed.2006.11.004Get rights and content

Abstract

This paper uses Demographic and Health Surveys data from 21 countries in sub-Saharan Africa to examine the use of maternal health services by teenagers. A comparison of maternal health care between teenagers and older women, based on bivariate analysis shows little variation in maternal health care by age. However, after controlling for the effect of background factors such as parity, premarital births, educational attainment and urban/rural residence in a multivariate analysis, there is evidence that teenagers have poorer maternal health care than older women with similar background characteristics. The results from multilevel logistic models applied to pooled data across countries show that teenagers are generally more likely to receive inadequate antenatal care and have non-professional deliveries. An examination of country-level variations shows significant differences in the levels of maternal health care across countries. However, there is no evidence of significant variations across countries in the observed patterns of maternal health care by maternal age. This suggests that the observed patterns by maternal age are generalizable across the sub-Saharan Africa region.

Introduction

The maternal mortality ratio in Africa remains the highest in the world and despite on-going efforts, the average ratio actually increased from 870 per 100,000 live births in 1990 to 1000 per 100,000 live births in 2001. Pregnancy among adolescents, in particular, has been noted to present a unique and frightening picture (WHO, 2004). Experts on reproductive health have painted a grim picture of maternal and child health in the region and warned that the situation could worsen in the next decade if immediate remedial actions are not taken by Africa's governments and development partners (SAHIMS, 2004). One area of concern relates to poor maternal health care in the region. The low number of births attended to by skilled health personnel has been observed to be strongly correlated with high maternal mortality rates (Buor & Bream, 2004). The United Nations (2005) recognizes professional care at birth as one of the key factors that can lower maternal mortality.

Antenatal and delivery care are both critical for maternal and newborn health. Although the effectiveness of antenatal care in preventing serious maternal morbidity and mortality has recently been questioned, there is no doubt that appropriate maternal heath care can avert adverse pregnancy outcomes for the mother and newborn mainly through preventive measures or effective management of obstetric complications. Previous studies suggest that unplanned pregnancies are less likely to receive appropriate maternal health care (Joyce, Kaestner, & Korenman, 2002; Magadi, Madise, & Rodrigues, 2000) and since teenagers are more likely to have unplanned pregnancies (see, for example, Magadi, 2003), they are a particular group of interest. It is generally recommended that prenatal visits start early in pregnancy and continue at regular intervals throughout the pregnancy to mitigate potential pregnancy complications. With respect to delivery care, it is important that mothers deliver their babies in hygienic settings with suitable equipment and supplies, and in the presence of a qualified attendant to reduce the risk of infections and ensure that any complications can be effectively managed.

In this paper, we use data from the Demographic and Health Surveys (DHS) from 21 countries in sub-Saharan Africa to examine the association between maternal age and two indicators of maternal health care: antenatal and delivery care. The specific objectives are to: (i) explore how the use of maternal health services by teenagers in sub-Saharan Africa compares with that of older women; (ii) determine the extent to which observed differences in the use of maternal health services between teenagers and older mothers vary across countries of sub-Saharan Africa; and (iii) examine the contextual country effect on the use of maternal health services among teenagers in the region.

Our interest in antenatal and delivery care among teenagers in sub-Saharan Africa is driven by a number of factors. In an analysis of levels, trends and differentials in antenatal care in developing countries, Abou-Zahr and Wardlaw (2003) found that while women were, in general, more likely to present themselves for antenatal care during the first trimester, sub-Saharan Africa was an exception. In this region, most women were more likely to wait until the second trimester and a substantial proportion presented themselves in the third trimester. Even though some studies have found no evidence of an effect of prenatal care on pregnancy outcomes (e.g., Hellerstedt, Pirie, & Alexander, 1995; Thomas, Golding, & Peters, 1991), others have established a significant association (e.g., Balcazar, Hartner, & Cole, 1993; Blankson et al., 1993; Goldani, Barbieri, Silva, & Bettiol, 2004; Magadi, Madise, & Diamond, 2001). Moreover, high levels of antenatal care use are also likely to be associated with the use of safe delivery care, hence, reduced adverse pregnancy outcomes (Abou-Zahr & Wardlaw, 2003; Bloom, Lippeveld, & Wypij, 1999). The importance of antenatal care is more apparent for sub-Saharan Africa given that the region is characterized by high maternal mortality and morbidity and any opportunities for contact with health services are likely to make an impact (Abou-Zahr & Wardlaw, 2003; Carroli, Rooney, & Villar, 2001). For teenagers, the fact that antenatal care services in the region are not often oriented to their needs makes the health risks associated with their pregnancies and childbearing more pronounced than those of older women (Zabin & Kiragu, 1998).

There is on-going debate on the relative importance of parity as opposed to maternal age in determining poor pregnancy outcomes among teenagers. Second teenage pregnancies have been found to be strongly associated with adverse outcomes than first pregnancies (see for example Akinbami, Schoendorf, & Kiely, 2000; Blankson et al., 1993; Hellerstedt et al., 1995; Smith & Pell, 2001). Blankson et al. (1993) found that adolescents were more likely to present themselves late for prenatal care by about two and half weeks and make fewer total clinic visits in their second pregnancies. This could partly account for the adverse outcomes associated with the second pregnancy among teenagers. Another critical issue surrounding maternal health care among teenagers in sub-Saharan Africa is pregnancy wantedness and acceptance by the teenagers themselves as well as the society, especially in cases of premarital childbearing. Unintended pregnancies have been shown to be associated with use of fewer health inputs such as prenatal care because of delay in recognizing or acknowledgement of pregnancy (Joyce & Grossman, 1990; Joyce et al., 2002; Kathryn, Landry, & Darroch, 1998; Magadi et al., 2000). Births to unmarried teenagers are often unintended and most of the young mothers are in more precarious economic position. Such circumstances greatly increase the chance of poor outcomes both in the short and long-term (Singh, 1998). Furthermore, the socio-cultural contexts in most of sub-Saharan Africa accord teenagers little power over decision-making in terms of seeking multiple health care paths for maternal health care.

Besides demographic factors such as parity and marital status, individual socio-economic characteristics such as mothers’ education, social status, place of residence and, religion have also been observed to influence use of maternal health care services in the developing countries (Abou-Zahr & Wardlaw, 2003; Jejeebhoy, 1995; Mekonnen & Mekonnen, 2003; Ojanuga & Gilbert, 1992). In particular, the impact of education on reproductive behaviour has been observed to be greatest beyond specific threshold levels of education, and when education offers women an expanded role in family decisions and control over resources (Jejeebhoy, 1995). It is also important to recognize the potential effect of contextual country factors, including socio-economic context, national policies relating to provision and cost of health care as well as socio-cultural norms and practices. The fact that gross national product (GNP) per capita and health expenditure are strongly associated with maternal mortality (see, for example, Buor & Bream, 2004) suggest that these factors are potentially significant in maternal health care. Furthermore, higher health expenditure per capita has been observed to be associated with improved performance of national health systems (Evans, Tandon, Murray, & Lauer, 2001).

A recent study on maternal health care in sub-Saharan Africa based on descriptive statistics, confirmed the importance of individual socio-economic and demographic factors such as mother's education, urban/rural residence, parity and wealth distribution in antenatal care (Abou-Zahr & Wardlaw, 2003). However, age was not significant, although older women had slightly lower levels of antenatal care use. In this article, we expand on the analysis of the association between maternal age and maternal health care by comparing teenagers and older women using multivariate and multilevel modelling to simultaneously take into account other important factors, including contextual country-level effects. This study places particular emphasis on country-level variations to shed some light on the nature and extent of observed and unobserved contextual country level effects on maternal health care among teenagers in sub-Saharan Africa. We recognize that use of maternal health care services can also be influenced by service availability and accessibility as well as provider attitudes (Kyomuhendo, 2003; Magadi et al., 2000; Stekelenburg, Kyanamina, Mukelabai, Wolffers, & Roosmalen, 2004), but data limitations do not allow us to explicitly examine these factors.

Section snippets

The data

The study is based on DHS conducted in 21 countries of sub-Saharan Africa during the late 1990s or early 2000s. Selection of countries was based on availability of comparative data at the time of the analysis. The DHS apply probability-based sampling to provide nationally representative samples of women of reproductive age (i.e., aged 15–49 years). This study compares the maternal health care indicators of teenagers aged 15–19 years with those of older women aged 20–34 and 35–49 years. These

Bivariate analysis

Table 1 shows the distribution of births by maternal age in the last three years prior to the survey for 21 countries in sub– Saharan Africa. In all countries, the majority of the births (63–72 percent) occurred to women aged 20–34 years. Another significant proportion of births (12–24 percent) occurred to teenagers, while births to women aged 35–49 years made up less than 20 percent of births in all countries. On average, the proportion of births to teenagers was about one fifth of the total

Discussions and conclusions

The main objectives of this paper were threefold: to examine how maternal health care indicators (antenatal and delivery care) of teenagers compare with those of older women in sub-Saharan Africa; to determine the extent to which differences in maternal health care between teenagers and older mothers vary across countries in the region; and to examine the country-effect on maternal health care among teenagers in the region. Preliminary bivariate analysis showed that a very high proportion of

References (38)

  • D. Buor et al.

    An analysis of the determinants of maternal mortality in sub-Saharan Africa

    Journal of Women's Health

    (2004)
  • G. Carroli et al.

    How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

    Paediatric and Perinatal Epidemiology

    (2001)
  • Dmytraczenko, T., Rao, V., & Ashford, L. (2003). Health sector reform: How it affects reproductive health. Population...
  • D.B. Evans et al.

    Comparative efficiency of national health systems: Cross national econometric analysis

    British Medical Journal

    (2001)
  • A. Gage

    Premarital childbearing, unwanted fertility and maternity care in Kenya and Namibia

    Population Studies

    (1998)
  • M.Z. Goldani et al.

    Trends in prenatal care use and low birthweight in southeast Brazil

    American Journal of Public Health

    (2004)
  • H. Goldstein

    Multilevel statistical models

    (1995)
  • W.L. Hellerstedt et al.

    Adolescent parity and infant mortality, Minnesota, 1980 through 1988

    American Journal of Public Health

    (1995)
  • A User's guide to MlwiN multilevel models project

    (2000)
  • Cited by (132)

    • Learner pregnancy in South Africa's Eastern Cape: The Factors affecting adolescent girls' school withdrawal during pregnancy

      2021, International Journal of Educational Development
      Citation Excerpt :

      Upon discovering the pregnancy, girls frequently report being stressed and upset (Kaye, 2008; Mkhwanazi, 2010; Ngabaza, 2011; Sodi and Sodi, 2012) or considering a termination of the pregnancy (Mkhwanazi, 2010) which may impair their focus for school. Pregnant women in low- and middle-income countries show a higher risk of developing certain medical conditions (WHO, 2004), but adolescent mothers are less likely to address these through maternal health services (Hackett et al., 2019; Magadi et al., 2007). Untreated medical problems could affect the ability to continue schooling, especially since South Africa’s national policy prescribes that medically unfit learners can be asked to take leave at any point during their pregnancy (South African Department of Education, 2007).

    View all citing articles on Scopus
    View full text