Déterminants et inégalités d’utilisation des services obstétricaux essentiels dans les pays à revenu faible et intermédiaire

Background Each year, 289 000 women die from complications related to pregnancy, childbirth or the postnatal period, and 2.9 million newborns decease before reaching 28 days of life. The near totality (99%) of maternal and neonatal deaths occur in low- and middle-income countries (LMICs). Utilization of essential obstetric care services including skilled birth attendance (SBA) and postnatal care (PNC) largely contributes to the reduction of maternal and neonatal morbidity and mortality. There is a strong need to assess the determinants and inequalities in coverage of SBA and PNC services, to inform health policy planning. Objectives 1. Systematically assess the socioeconomic, geographic and demographic inequalities in PNC services utilization in LMICs. 2. Evaluate the effect of Burkina Faso’s 2007 user-fee subsidy policy on SBA rate across socioeconomic status (SES) strata. Methods 1. We conducted a systematic review of the association between PNC services utilization and key determinants, including a meta-analysis of PNC use across socioeconomic status quintiles, and place of residence (urban vs. rural). 2. We used a quasi-experimental design. The data sources were two representative surveys (n=1408 and n=1403) carried out in 2008 and 2010, respectively, of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel segmented Poisson regression models were used to assess the effect of subsidy on SBA rate. We estimated adjusted rate ratios and rate differences as a function of time and socioeconomic status level.  Results 1. The pooled odds ratio (OR) (95% CI) estimates for highest SES women (quintile 5, Q5), Q4, Q3 and Q2 (reference: poorest quintile, Q1) were respectively: 2.27 (1.75 – 2.93); 1.60 (1.30-1.98); 1.32 (1.12-1.55); and 1.14 (0.96-1.34). Meta-analysis also showed a PNC utilization divide between urban and rural women: OR (95% CI) = 1.36 (1.01-1.81). Narrative assessment of studies identified a gradient in PNC coverage across education levels.   2. For low-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 24% higher (95% CI: 4-46%) than expected in the absence of subsidy policy introduction. The magnitude of the apparent effect decreased over time, with the corresponding estimates (95% CI) being 22% (3-45%) at 6 months, 20% (1-43%) at 12 months, and 17% (-4-42%) at 24 months after the policy introduction. Furthermore, the magnitude of the association varied across SES strata, with the apparent effect being most pronounced in the low SES stratum.  Conclusions 1. PNC utilization remains inequitable across socioeconomic status and geographic access to health facilities in LMICs.  2. Our study suggests that introduction of user fee subsidy in Burkina Faso resulted in sustained increase in the rate of SBA, especially among low-SES women. This evidence should inform maternal and child health programmes and guide health policies and health care systems in LMICs.

Keyphrases: Essential obstetric care, Equity, Global health, Healthcare services utilization, Maternal and infant health, Maternal and neonatal mortality, Postnatal care services, Skilled birth attendance, Socioeconomic inequalities, Subsidy policy