DISPARITIES IN WOMEN’S REPRODUCTIVE HEALTH IN WEST AND CENTRAL AFRICA: EXPLORING CONTEXTUAL DETERMINANTS OF ACCESS, USE AND QUALITY OF CARE
Background: The West and Central African region bears the highest burden of maternal mortality globally. Objectives: The aims of this study were to: examine the association between women’s perception of domestic violence (DV) and choice of contraceptive method; and assess the relationship between individual and community socioeconomic status (SES) and the quality of prenatal care and the location of childbirth. Methods: I used data from the fourth round of the UNICEF Multiple Indicators Cluster Surveys for seven West and Central African countries (Central African Republic [CAR], Chad, Democratic Republic of Congo [DRC], Ghana, Nigeria, Sierra Leone, and Togo). For my first objective, the sample included 80,055 reproductive aged women. Perception of DV was measured as no, low, or high tolerance of wife beating. Contraceptive method was coded as none, traditional (e.g., periodic abstinence/rhythm), or modern (e.g., birth control pills). I used multinomial logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the odds of using traditional or modern methods versus none. For my second and third objectives, the sample included 24,718 and 32,487 women, respectively, who gave birth within the last two years preceding the survey. Community SES was defined as low or high poverty index, and individual SES variables included women’s education and wealth. Quality of prenatal care was coded as low or high, and the location of childbirth was coded as home or health institution. I used multilevel logistic regression to estimate the fixed and random effects of individual and community SES on the quality of prenatal care (objective 2) and the place of childbirth (objective 3). Findings: After accounting for socio-demographic characteristics, women with low DV tolerance had lower odds of using traditional or modern methods compared to those with no tolerance (OR=0.87; 95% CI: 0.78, 0.98 and OR=0.86; 95% CI: 0.78, 0.95, respectively). Women with high DV tolerance had 28% lower odds of traditional method use and 38% lower odds of modern method use compared to women with no tolerance (95% CI: 0.60, 0.90 and 95% CI: 0.59, 0.88, respectively). Furthermore, after adjusting for individual and contextual characteristics, residence in a poor community was associated with reduced odds of a woman receiving high quality prenatal care in six countries (CAR: OR=0.76; 95% CI: 0.58, 0.98; Chad: OR=0.48; 95% CI: 0.32, 0.74; Ghana: OR=0.86; 95% CI: 0.61, 0.97; Nigeria: OR=0.74; 95% CI: 0.61, 0.92; Sierra Leone: OR=0.71; 95% CI: 0.57, 0.91; and Togo: OR=0.80; 95% CI: 0.47, 0.91). In DRC, however, the association was not statistically significant (OR=0.92, 95% CI: 0.63, 1.33). In addition, residence in a poor community was associated with reduced odds of having an institutional delivery in five countries (CAR: OR=0.69; 95% CI: 0.54, 0.89; Chad: OR=0.85; 95% CI: 0.65, 0.99; DRC: OR=0.82; 95% CI: 0.71, 0.83; Ghana: OR=0.88; 95% CI: 0.56, 0.99; and Nigeria: OR=0.87; 95% CI: 0.68, 0.98). In Sierra Leone and Togo, the associations were not statistically significant (OR=0.93, 95% CI: 0.69, 1.12; and OR=0.92, 95% CI: 0.39, 1.61, respectively). There were significant community-level variations in the quality of prenatal care and the use of institutional delivery in the seven countries. Conclusion: My findings suggest that women’s tolerance of DV is associated with decreased odds of any contraceptive method use. Policies that seek to increase the prevalence of modern contraceptive use need to consider perceptions about DV that may affect women’s use of contraception. These results also highlight marked socioeconomic inequalities in the quality of prenatal care that women receive, and the use of institutional delivery services. Living in close proximity to other poor households appears to decrease the likelihood of receiving the recommended quality of prenatal care, and giving birth in a health facility. My findings suggest that greater attention should be paid to efforts to ameliorate not only individual but also contextual barriers to access to reproductive health care. It is especially important to remove economic and social barriers to the use of maternal health services among women in West and Central Africa.