Determinants of maternal health and health-seeking behavior in sub-Saharan Africa: The role of quality of care

Author(s): Afulani, Patience Akelen-era | Advisor(s): Harrison, Gail G; Pebley, Anne R | Abstract: This dissertation advances understanding of how distal factors affect maternal health and health seeking behavior: by examining the links between place of residence and socioeconomic status (SES); quality of antenatal care (ANC); use of skilled birth attendants; and pregnancy outcomes. The dissertation is motivated by two main questions: Why are deliveries by skilled attendants low in most of sub-Saharan Africa, despite high antenatal attendance? And what accounts for the disparities in use of skilled birth attendants within countries? I hypothesize that differentials in quality of care partly explain the gap between antenatal attendance and use of skilled birth attendants, the rural/urban and SES differentials in the use of skilled birth attendants, as well as differentials in pregnancy outcomes. Data for the analysis are from the Ghana Maternal Health Survey and the World Health Survey for Ghana and Burkina Faso. I employ multilevel linear and logistic regressions with mediation and moderation analyses to examine the intervening and conditional effects. The first three chapters present the introduction, background, and theory sections respectively; chapter 4 presents an overview of the data, variables, and sample distributions; and chapter 8 is the concluding chapter. The dissertation has three empirical chapters.In the first empirical chapter (chapter 5), I examine the factors that affect the quality of antenatal care women receive--focusing on place of residence and SES (education and wealth); the interaction between these factors; and the mediating role of ANC timing, frequency, facility and provider. The results show that urban residence and higher SES are positively associated with higher ANC quality, but the urban effect is completely explained by sociodemographic factors. Specifically, about half of the urban effect is explained by education and wealth alone, with other variables accounting for the remainder. The effects of education are conditional on wealth and are strongest for the poorest women. Starting ANC visits early and attending the recommended four visits as well as receiving ANC from a higher-level facility and from a skilled provider, are associated with higher quality ANC. These factors partially explain the SES differentials in quality of ANC.In the second empirical chapter (chapter 6), I examine the factors that influence the use of skilled birth attendants, focusing on the mediating role of quality of care. The results show that higher quality ANC, frequent ANC visits, and receiving ANC in higher level or private facilities increase the odds of using a skilled birth attendant. As expected urban residence and high SES are also associated with higher use of skilled birth attendants, but the rural/urban and SES differential in use of skilled attendants that is mediated by ANC quality is only marginally significant in most of the models. The rural/urban and SES effects are also not conditional on the ANC quality. In the third empirical chapter (chapter 7), I examine the factors associated with pregnancy outcomes, focusing on the role of ANC quality. The results show that higher quality ANC decreases the odds of having a stillbirth by almost half, net of other factors including delivery provider and place. The other health service factor associated with lower odds of having a stillbirth in the multivariate analysis is attending at least four antenatal visits.My findings suggest pregnant women in SSA experience significant disparities in the quality of ANC, with poor illiterate women receiving the worst care. Poor quality ANC is contributing to the low utilization of skilled birth attendants, despite high antenatal attendance, and to poor pregnancy outcomes. The differentials in quality of care are also potentially contributing to the differentials in use of skilled birth attendances by SES and place of residence, but this needs more research. Targeted efforts to increase quality of ANC could significantly improve maternal and fetal outcomes and reduce maternal health disparities in SSA.