Elsevier

Health Policy

Volume 99, Issue 3, March 2011, Pages 210-218
Health Policy

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

https://doi.org/10.1016/j.healthpol.2010.10.010Get rights and content

Abstract

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.

Introduction

Recent estimates indicate that approximately 350,000 maternal deaths [1] and 4 million neonatal deaths [2] occur annually, of which respectively close to 50% and 30% are in sub-Saharan Africa (SSA). With an annual decline in maternal mortality of 0.1% [3] and a 5% increase in the proportion of neonatal deaths which occur in the continent [2], SSA is far from achieving the objectives set by Millennium Development Goals of halving maternal deaths and reducing child deaths by two thirds by 2015.

There is a strong positive correlation between skilled attendance at birth, defined as the presence of someone with midwifery skills able to manage a normal delivery, recognize complications, and refer in due time, and lower maternal and neonatal death [2], [4], [5], [6], [7], [8]. In fact, skilled attendance at birth has been identified as the single most important factor in preventing maternal deaths [9] and as an important element in reducing neonatal death [2]. In turn, focused antenatal care (ANC) has been shown to provide opportunities for the early detection of potential obstetric risks and, through counselling and education, motivate women to seek skilled attendance at birth [10], [11], [12], [13]. Thus, access to and use of adequate maternal care services, including both ANC and skilled attendance at birth, is essential to reduce both maternal and neonatal mortality [6], [7], [8]. Most current deaths in fact, could be avoided if only known medical interventions were available and accessible to the population in need [2], [3], [4].

A number of studies have indicated the presence of multiple barriers hampering women's access to maternal care services [10], [14], [15]. In particular, following their introduction in the 1980s and 1990s [16], the imposition of user fees has been shown to dissuade service utilisation, to delay the process of seeking care, and to increase the use of informal care [10], [17], [18], [19], [20].

These considerations on the detrimental effect of user fees have led a number of researchers and policy makers to conclude that the alleviation of financial barriers constitutes a sine qua non to advance progress towards MDG 5 [21], [22], [23], [24], [25], [26].

A number of countries in SSA have responded to this international call and have either strongly reduced or completely abolished user fees for maternal care services [27], [28]. These rapid policy changes have been evaluated in terms of process indicators and in terms of their impact on time-trends in service utilisation [29], [30], [31], [32], [33], [34]. In spite of undoubted progress towards greater coverage rates, however, evidence from various African settings has shown that one quarter to one half of women continue not to attend ANC and not to seek skilled attendance at birth even after the reduction of user fees [32], [33], [34], [35], [36].

It is therefore of utmost importance to understand who continues to remain excluded from access to maternal care services even following the reduction of user fees. With the exception of one paper from Ghana [37], analyses of determinants of utilisation of both ANC and skilled attendance at birth date back to a time when user fees where still in place and are therefore no longer adequate to inform policy making [10], [11], [15], [38], [39], [40]. Understanding the remaining barriers to access through an analysis of the determinants of utilisation represents the first step towards the establishment of comprehensive policies for the reduction of maternal and neonatal mortality in SSA.

This study sets to fill this gap in knowledge by providing an analysis of the determinants of utilisation for both ANC and skilled attendance at birth in Burkina Faso, following the implementation of a financing policy reducing user fees for maternal care services.

Section snippets

Study setting

The study took place in the Nouna Health District (NHD), a rural district located in north-western Burkina Faso at the border with Mali and at about 300 km from the capital Ouagadougou. The district has a population of approximately 311,000 distributed in 300 villages, served by 25 first-line health facilities, Centres de Santé et Promotion Sociale (CSPS), and one district hospital located in Nouna town.

With an estimated 332 maternal deaths per 100,000 live birth [1] and 19 neonatal deaths per

Results

Among the 1050 households included in the survey, all 435 women who reported a pregnancy in the 12 months prior to the interview date, were interviewed. These 435 women were clustered in 356 households. Of all women in the sample, nearly 76% had attended at least 3 ANC visits and 72% had delivered in a health facility (69% in a CSPS and 3% in the district hospital). Complete information could be ascertained for 429 women, who were included in the logistic regression models.

Table 2 reports the

Discussion

In line with evidence from elsewhere in SSA [32], [33], [34], [35], this study indicated that a considerable proportion of pregnant women, about one quarter, still did not use ANC regularly and did not benefit from skilled attendance at birth. Use of maternal care services, however, was higher than in many other SSA countries. In countries as diverse as Tanzania [13], the Ivory Coast [39], and Nigeria [11], [40], regular ANC and skilled attendance at birth were consistently observed to stand

Conclusions

Findings from this study indicate that the reduction of user fees is instrumental to secure equitable access to care across socio-economic groups, but alone it is not sufficient to ensure that all women use ANC and benefit from skilled attendance at birth. As distance continues to constitute a major barrier to access, findings from this study call for the adoption of urgent measures, such as free or low cost emergency transport and the wider availability of skilled attendance at birth closer to

Contributions

OM, AJ, and MDA were in charge of the original study design. MDA, JT, and MY designed the data collection tools. MDA, JT, and VL were responsible for data collection. MDA conducted the data analysis with support from VL, VR, and MS. All authors contributed to the interpretation of the results. MDA wrote the manuscript with contributions from all authors. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the

Conflict of interest statement

All authors declare that they have no conflict of interest.

Acknowledgements

This study was supported by Collaborative Research Grant SFB 544 (Project D4) of the German Research Society (DFG). Valéry Ridde is a Canadian Institutes of Health Research (CIHR) New Investigator. The study sponsor had no role in the study design, in the collection, analysis, and interpretation of data, in the writing of the manuscript, or in the decision to submit it for publication. The authors would like to thank the staff of the Centre de Recherche en Santé de Nouna and the staff of the

References (80)

  • H.E. Onah et al.

    Factors associated with the use of maternity services in Enugu, Southeastern Nigeria

    Social Science & Medicine

    (2006)
  • S. Pokhrel et al.

    Illness reporting and demand for medical care in rural Burkina Faso

    Social Science & Medicine

    (2010)
  • A.J. Gage

    Barriers to the utilisation of maternal health care in rural Mali

    Social Science & Medicine

    (2007)
  • S. Thaddeus et al.

    Too far to walk: maternal mortality in context

    Social Science & Medicine

    (1994)
  • E. Brazier et al.

    Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

    Social Science & Medicine

    (2009)
  • R. Jewkes et al.

    Why do nurses abuse patients? Reflections from South African obstetric services

    Social Science & Medicine

    (1998)
  • The World Health Organisation

    Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank

    (2007)
  • U. Stokoe

    Determinants of maternal mortality in the developing world

    The Australian & New Zealand Journal of Obstetrics & Gynaecology

    (1991)
  • P. Fournier et al.

    Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali

    Bulletin of the World Health Organization

    (2009)
  • C. Ronsmans et al.

    Maternal mortality and access to obstetric services in West Africa

    Tropical Medicine & International Health

    (2003)
  • The World Health Organisation

    Reduction of maternal mortality. A Joint WHO/UNFPA/UNICEF/World Bank Statement

    (1999)
  • S. Gabrysch et al.

    Still too far to walk: literature review of the determinants of delivery service use

    BMC Pregnancy Childbirth

    (2009)
  • S. Babalola et al.

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

    BMC Pregnancy Childbirth

    (2009)
  • S. Renkert et al.

    Opportunities to improve maternal health literacy through antenatal education: an exploratory study

    Health Promotion International

    (2001)
  • R.N. Mpembeni et al.

    Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets

    BMC Pregnancy Childbirth

    (2007)
  • T.H. Holtz et al.

    Use of antenatal care services and intermittent preventive treatment for malaria among pregnant women in Blantyre District, Malawi

    Tropical Medicine & International Health

    (2004)
  • G. Carrin et al.

    Strategies for health care finance in developing countries

    (1992)
  • G. Hutton

    Is the jury still out on the impact of user fees in Africa? A review of the evidence from selected countries on user fees and determinants of health service utilisation

    East African Medical Journal

    (2004)
  • V. Ridde

    Fees-for-services, cost-recovery, and equity in a district of Burkina Faso operating the Bamako Initiative

    Bulletin of the World Health Organisation

    (2003)
  • Amnesty International

    Giving Life, Risking Death. Maternal Mortality in Burkina Faso

    (2009)
  • The Global Campaign for the Health Millennium Development Goals

    Leading by example – protecting the most vulnerable during the economic crisis

    (2009)
  • N. Meda et al.

    From evaluating a skilled care initiative in rural Burkina Faso to policy implications for safe motherhood in Africa

    Tropical Medicine & International Health

    (2008)
  • J. Kippenberg et al.

    Detention of insolvent patients in Burundian hospitals

    Health Policy Plan

    (2008)
  • ITM Antwerp. Policy Guidance Note on Removing User Fees in the Health Sector;...
  • Ridde V, Morestin F. Une recension des écrits scientifiques sur l’abolition des frais aux usagers dans les services de...
  • V. Ridde et al.

    Les pression exercées par l’abolition du paiment de soins sur les systèmes de santé

    (2010)
  • V. Ridde et al.

    A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa)

    BMC Health Services Research

    (2009)
  • S. Witter et al.

    Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana

    Global Health Action

    (2009)
  • S. Penfold et al.

    Evaluation of the delivery fee exemption policy in Ghana: population estimates of changes in delivery service utilisation in two regions

    Ghana Medical Journal

    (2007)
  • W. Bosu et al.

    Effect of delivery care user fee exemption policy on institutional maternal deaths in the central and Volta regions of Ghana

    Ghana Medical Journal

    (2007)
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