Sociodemographic determinants of non-use of antenatal care services in Central African Republic: MICS6 (2018-2019) data analysis

¹Hassan First University, Laboratory of health sciences and technologies, Higher Institute of Health Sciences, Settat, Morocco, ²University of Bangui, Bangui, Central African Republic

^&Corresponding author
Ousseni Issa, Hassan First University, Laboratory of Health Sciences and Technologies, Higher Institute of Health Sciences, Settat, Morocco

Introduction    

Although there was a significant progress accomplished during the 20th century, maternal mortality remains a public health concern in the developing countries. Following the implementation of several programs by converting from global goals into national planning targets as the millennium development goals that we can highlight some improvement, nevertheless the target of maternal mortality ratio (MMR) is not fulfilled [1]. In September 2015 the Sustainable Development Goals recognized as more ambitious framework and more aspirational than previous programs were implemented. To reduce the global maternal mortality rate to less than 70 per 100,000 live births by 2030 [2]. To reach these goals its seems difficult for some Africans countries [3]. Throughout 2020, the African region accounted for 69% of maternal deaths worldwide. Particularly sub-Saharan countries with 531 deaths for 100,000 live births. According to WHO, Central African Republic (CAR) counted 835 deaths for 100,000 live births in the same year.

In such situation, there is an urgent need to establish a policy to reduce the MMR in CAR. The investigations were conducted to provide insight for the decision, the research has identified the root causes of this problem, which include difficulties with access to care, the inadequacy and uneven distribution of healthcare staff, the management of obstetric emergencies and the referral system [4]. Furthermore, the multiple military and political crises in this country played a major role in the degradation of healthcare infrastructure and system [5]. However, access to antenatal care continue to be a significant challenge in the developing countries, a limited proportion of women meet WHO recommendations for antenatal care use in sub-Saharan African countries [6]. A study of 31 countries in sub-Saharan Africa from 2010 to 2018 revealed that 13% of women did not utilize antenatal care while 35% and 53% respectively partially and adequately utilized the service [7].

Many studies have revealed the impacts of non-use of antenatal services such in Ghana that low attendance at antenatal care services increased the risk of adverse pregnancy outcomes. Similarly in Kenya, high neonatal mortality was observed among women who have not used antenatal care [8,9]. The antennal care use is subject to several influencing factors. Based on theoretical framework proposed by Ronald Andersen in 1968 and further developed [10,11]. A various of studies have demonstrated the impact of factors such a socioeconomics, predisposing, enabling and need factors effect on the ANC utilization in sub-Saharan Africa [12,13]. Even if the issue of ANC is subject of research in the most developing countries with the intention of reducing the maternal and child mortality burden, we noticed the lack of information on the factors influencing the ANC use in CAR. For the better understanding of what factors have an influence on a reduced number of antenatal visits to lead the health policy makers, the aim of this study is to identify the sociodemographic determinants linked to non-use of antenatal care services in CAR.

Methods     

Data and sample: this study used data from the Multiple Indicator Cluster Surveys (MICS6) conducted in 2018-2019 used a stratified two-stage cluster sampling design to collect data from rural and urban households across CAR. In the surveyed households, 9202 were successfully interviewed. This study includes 7083 women aged 15-49 years who had given birth within two years preceding the survey.

Variables

Dependent variable: according to WHO former recommendation on having at least four antenatal care visits, the outcome variable in this study is non-use of ANC services categorised 1 for women who attended less than 4 times (none to 3 ANC), and 0 for those have four or more times (= 4 ANC).

Independent Variables: in the study, the following independent variables selected based on the literature review on the determinants of the use and non-use of prenatal care services in developing countries: age was categorized as [15-19 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years 45-49 years]; Education [was defined as none, primary and secondary or higher]; Household wealth [poorer, middle, richer]; Residence [rural, urban]; Media exposure (listening radio) [never, less than1 per week, one per week, everyday]; Parity [1-3, 4-5, >5 children]; age at first marriage [< 15 years, 15-19 years, >20 years, NA]; Use of contraception [yes, no]; Marital status [single, married, divorced or widowed]; Region (region 1, region 2, region 3, region 4, region 5, region 6, region 7); Religion [catholic, protestant, muslim, animist, no religion, other religion]; Ethnicity [Haoussa, Sara, mboum, gbaya, mandja banda, Zandé nzakara, yakoma/sango, Gbaka/Bantou, other ethnicity].

Data availability: access to this data was granted following a request that we submitted to UNICEF website after a brief description of the protocol and purpose of the study, we received official approval for access by e-mail.

Ethics approval and consent to participate: ethical approval for the Multiple Indicator Cluster Surveys (MICS6) was obtained by the Central African Institute of Statistics and Economic and Social Studies (ICASEES). The research protocol was submitted to and approved by the scientific committee of the faculty of health sciences of Bangui (FACSS).

Data analysis

The analysis in this study was conducted in three phases using the Statistical Package for Social Science (SPSS) version 20.0. first of all, a descriptive analysis of the socio-economic characteristics of sampled respondents was performed to present a frequency and percentage. Then chi-Square test was used for bivariate analysis to describe the relationships between antenatal care utilization and the independent variables. Lastly, for the multivariate analysis a binary logistic regression was used to identify the determinants of non-utilization of ANC services in CAR with an odds ratio was accepted at a 95% CI, and a p value < 0.05 was stated as statistically significant.

Results     

Descriptive and bivariate analysis

The sociodemographic characteristics of the respondents as reported in method section; in this study 7083 women was surveyed. 80.1 % were currently married or in a union, 13.9 % were divorced, separated, or widowed, and only 6 % remained single. The age of respondents varied from 15 to 49 years, with a mean of 30 years (standard deviation=8.4 years). Women living in region 7 (Bangui) represented 19.4% followed by these living in region 1 16.3% succeeded by others region. The results of place of residence showed a slight increase above the average for women who resides rural area 58.2% compared to women who resides an urban area 41.8. Concerning education, 56.3% of the respondents have a basic level (primary) and 36.1% have no education. While only 7.6% have a secondary or higher education, this proportion is modest. Regarding religious affiliation, the three predominant religions represented 97%. The results showed that more than half 58% were protestants, 27.4% were Catholics and 11.6% were Muslims. The main ethnicity was Gbaya 28.4% and Banda 21.2%. The prevalence of maternal use of antenatal care by number of visits is presented in (Figure 1). 60% of women surveyed did not have any ANC visit during their recent pregnancy, women who made less than four ANC visits (1 to 3) was 18% and the prevalence of women who made the recommended number of ANC visits (≥ 4) was about 22%. The result of bivariate analysis from chi-square (Table 1) shows that socio-demographic factors including all the individual, household, and community level factors were significantly associated with the non-utilization of ANC services by women in CAR (p < 0.05).

Multivariate analysis

Factors associated with non-use of the recommended number of ANC visits To assess the net effect of each variable included in the model or risk factor, binary logistic regression was used to identify the sociodemographic determinants linked to non-use of antenatal care services in CAR. The results summarized in (Table 2) reveal that the sociodemographic factors including maternal age, place of residence, marital status, education level, socio-economic status, parity, age at first marriage, use of contraceptive were significantly contributed to the non-attendance of antenatal care services (p<0.05). Nevertheless, the region, religion, access to media (listening to radio), ethnicity except Gbaka/Bantou group are not statistically associated with the non-utilization of ANC services by women in CAR (p < 0.05). Maternal age was significantly associated with non-use of ANC services in CAR. In fact, as the maternal age increases the likelihood of non-use increase in parallel. Furthermore, a youngest age group (15-19) has 97.9% (OR = 0.021 [IC 95%: 0.012–0.037] p <0.001) less likely to perform less than four ANC visits compared to oldest age group (45-49). Place of residence was significantly associated with ANC services use. Women who resided rural area have 1.2 times (OR = 1.217 [IC 95%: 1.027–1.442] p = 0.023) more likely to perform less than four ANC visits compared to an urban resident.

None educated women and those with primary education were respectively 2.1 times (OR = 2.133 [IC 95%: 1.628–2.796] p < 0.001) and 1.4 times (OR = 1.457 [IC 95%: 1.154–1.840] p < 0.002) more likely to attend less than four ANC visits compared to those who have higher education. Regarding the household wealth index, poorest women have 1.5 times (OR = 1.569 [IC 95%: 1.229–2.003] p < 0.001) more likelihood to have less than four ANC visits in contrast to richest. Ethnic group Gbaka/Bantou was 1.4 times (OR = 1.444 [IC 95%: 1.008–2.068] p =0.045) more likely to perform less than four ANC visits compared to others ethnic group. In contrast with women using contraceptive, non-user women were 1.2 times (OR = 1.270 [IC 95%: 1.095–1.473] p < 0.002) more likelihood to perform less than four ANC visits. In term of the parity, women with 4-5 and >5 children were respectively 46% (OR = 0.544 [IC 95%: 0.458–0.646] p < 0.001) and 64% (OR = 0.364 [IC 95%: 0.292–0.453] p < 0.001) less likely to perform less than four ANC visits compared to those with = 3 children.

Discussion     

The aim of this study is to contribute to a better understanding of the sociodemographic factors that determine the underutilization of ANC services by Central Africans‘ women. In accordance with WHO's previous recommendation standard notably, having at least four ANC visits. In order to achieve our goal, the data from the most recent survey MICS 6 conducted between 2018-2019 among women aged 15-49 years who had given birth within two years preceding the survey was used. The prevalence of ANC non-use was higher among central Africans' women. In fact, 78% of women surveyed performed less than four ANC visits this is a very high proportion. With 39.6% that have at least one ANC visit the findings shows that only 17% have made it in the first trimester according to WHO's recommendation. On the basis of a literature review, the sociodemographic characteristics of women surveyed were exanimated to explain this phenomenon that is ravaging the country by causing a high rate of maternal and child mortality. Age, place of residence, household wealth, education, parity, marital status, age at first marriage or union, and use of contraceptive were significantly associated with the non-utilization of ANC services by women in CAR (p < 0.05). However, the variables such as the region, ethnicity except Gbaka/Bantou group, religion, exposure to media were not significantly associated with the non-utilization of ANC services by women in CAR (p < 0.05). The non-association between the region and non-use of ANC services in CAR can be attributed to the context of armed conflict that has affected all region for numerous decades leading to destruction of health system. In contrast with South Sudan some of regions worst affected by inter-ethnic conflict was the most impacted and faced more difficulties to access to the ANC services [14]. Furthermore, in the Democratic Republic of Congo, which is plagued by armed conflict, women living in regions plunged into extreme and prolonged violence are more at risk of not using prenatal care services than those living in regions with moderate violence, due to the lack of care available [15]. In CAR, generally the cultural beliefs and traditions have a major influence on women's health choices. Just that our findings revealed that only women from Gbaka/Bantou ethnic group were associated with non-use of ANC services.

In western Ethiopia and Ghana ethnicity was also revealed to be a determinant factor of utilization of ANC [12,16]. Our result seems to reflect reality; these communities of hunter/gatherers nomadic lived in a forest environment detached from modern society. They ensure their own nourishment and treat themselves in the traditional way using plants [17]. The apprehension toward modern medical practices discourage many women from going to health centres for treatment. It would be essential to set up an awareness campaign in the Gbaka/Bantou community and mobile clinics, in agreement with their leaders, to inform them about the benefits and emphasize the necessity of antenatal care. Religion does not explain non-use of antenatal care services in CAR. The similar result was observed by Sirpe in Burkina Faso [18]. Regarding the same author all studies in which religion has an impact on the use of antenatal healthcare can be explained by the interaction between religion and household income. In ivory coast, Christian women are much more in favour of using obstetric care during pregnancy and childbirth than Muslim women, even if they are also in favour, unlike those of traditional religions and others who advocate using the services of fetishists and traditional healers [19]. Unexpectedly, the media exposure is not significantly associated with the non-utilization of ANC services by women in CAR. Nevertheless, a numerous studies showed the crucial role played by media on improving access to ANC services [20-22]. Our findings are possibly a consequence of armed conflict which had a devasting effect on communication system of the country by affecting media operations. Furthermore, the use of mass media is not effective more especially in rural area. As the maternal age increases the likelihood of non-use increase in CAR. In this context, non-use of antenatal care services by older women can be explained by poor previous experience or by the fact that they wrongly consider themselves to be sufficiently experienced in pregnancy. Abbani was also highlighted in northern region of Nigeria that oldest women (40-49 years) was more likely to not seek ANC services [23]. Similar results were emphasized by [14,15], with the delayed access to healthcare in line with the WHO recommendation. Contrary to age, the low parity women (=3 children) are more likelihood to attend less than four ANC visits compared to higher parity women >5 children. This outcome differs from our expectations; we believe that having more children can be a barrier to accessing ANC, such as in Kenya or in South Africa in Limpopo according to Mulondo, having more than five children may lead to delayed prenatal consultation [24,25]. In Africa or in many other parts of the world, higher parity is more likely to be associated with non-use of ANC services [26,27]. In Lubumbashi, DRC the women with higher parity consider ANC to be useless, worthless and deter them from seeking ANC services [28].

Culturally, in CAR when it comes to the first birth, for the most part the woman is under the supervision of her mother or grandmother, who can dissuade the young mother especially through their experience. This initial analysis can be supplemented by the situation of the unwanted pregnancy that the young mother may conceal her pregnancy at the first time in order to avoid parental or school sanctions. It should be mentioned that young women realise they are pregnant only after a few months of amenorrhoea that can lead to delaying first ANC visit and attend less than four ANC as recommended by WHO such in Ghana, Kenya and Malawi [29]. This study shows that the risk of not using ANC services is higher for a rural women compared to urban women. Similar findings have been reported across various nations especially developing countries [30-32]. In Ethiopia, the disparity in the availability of healthcare facilities and the lack of awareness among women in rural areas lead to non-utilization of ANC services [33]. In terms of healthcare service delivery in CAR, our findings may be attributed to the inconsistent spread of medical facilities and insufficient healthcare personnel in the rural areas [4]. Household wealth is essential for explaining use of ANC in CAR. Our study revealed that in contrast with richest women, the poor women are more likely to not use ANC. A notable example is that for South Sudan in the same context access to ANC is also associated with women economic status. The high cost of service, transport and drugs were among the reason why poor women do not seek ANC [14]. Similar findings have been reported in Nigeria, Ghana and Ethiopia [16,20,34]. Our result reflects the reality of a country with an almost non-existent medical cover and the fact that ANC is not free. The lack of local health care facilities, the cost of transport and road in poor condition all influence the decision not to seek prenatal care. In Burkina Faso, despite the policy of free prenatal care, women continues to pay for care [35]. However, according to Esopo free antenatal care remains an effective means of reducing maternal and infant mortality in sub-Saharan Africa [36]. The free antenatal care adopted by Doctors Without Borders in certain regions of the CAR has undoubtedly encouraged access to antenatal care. None educated women had an increased risk of not using ANC. Our results align with findings from research in northern Ghana and Democratic Republic of the Congo on Maternal education level and maternal healthcare utilization [37,38].

The under-use of health services is a consequence of the general level of understanding among these women, who are illiterate and do not know the signs of serious obstetric emergencies. An educated woman is aware of the risks involved in not using ANC, and therefore adheres to it. According to UNESCO report of 2011 « If every woman in sub-Saharan Africa had attended secondary school, 1.8 million lives could have been saved between 2003 and 2008». Educating girls gives them access to the world of work and empowers them. In sub-Saharan Africa, the level of education is positively associated with the use of antenatal care services [39]. It should be noted that the cultural context in CAR, where the lack of decision-making autonomy plays an important role, in many families it is only the men who decide on family health care. Their level of education will have a considerable impact on their decision-making with regard to their wives' reproductive health. In terms of marital status, divorced women or widowed tend to have fewer than four ANC visits as recommended by WHO in CAR. When it comes to this group considering that women are responsible of themselves and actively involved in their self-care after lack of husband's support, a possible explanation is the absence of adequate financial resources [40]. In Kenya, never married women were more likelihood to not receive adequate ANC [24]. In regard to age at first marriage or union, Women who married or entered into a union before their 16th birthday are more likely to perform less than four ANC. According to UNICEF, 26% of Central African girls are married before the age of 15. This prompted the government to adopt a strategy in 2024 to put an end to this practice, which contributes to the low school enrolment rate for girls and the high maternal mortality rate in CAR. Similarly, in Somaliland, women married at a very young age not only have fewer prenatal visits, but are also late for their first visit [41]. Women who do not adhere to family planning are very likely not to use prenatal consultations [14].

Strengths and limitations

The present study is the first to examine the sociodemographic determinants of non-use of ANC in CAR. The size of the sample is interesting for a conclusion on a national scale despite the context of armed conflict in several regions. Considering that the study was based on previously collected data, we were confronted with the absence of several variables considered essential for our study, such as data on the partner or husband, the woman's occupation, the desire for the last pregnancy and other variables. Exclusion of women without live birth children by the MICS data selection criteria may underestimate the scope of the problem at national level.

Conclusion     

Antennal care is widely recognized for its contribution to MMR reduction. Our study examined the sociodemographic factors influencing ANC utilization. The findings showed that maternal age, place of residence, marital status, education level, socio-economic status, parity, age at first marriage, contraceptive utilization determined ANC non-use in CAR. In order to reduce sociodemographic barriers to ANC services use, it's crucial for the government and its partners to intensify initiatives to enhance girls' literacy, to promote women's empowerment, to implement maternal mobile clinic programs to serve rural communities. The most effective policy for increasing the use of antenatal care services is to introduce a free maternal health policy, improve the health infrastructure and good distribution of qualified staff. Further research examining structural factors, human resources, and the quality of antenatal care and also documented the reasons why women do not seek antenatal care could significantly enhance our understanding.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Ousseni Issa established the research framework. Ousseni Issa, Noureddine El Khoudri and Fabien Kobio Beninga performed the data analysis and the interpretation. Saad Elmadani, Mohamed Chahboune, Milouda Chebabe, Germain Piamale drafted and critically revised the manuscript. All authors read and approved the final version of the paper.

Acknowledgments     

We would like to thank the Central African Institute for Statistics and Economic and Social Studies and UNICEF for making the data available.

Tables and figure     

Table 1: sample socio-demographic characteristics and Chi-square test of association (n=7083)

Table 2: odds ratios for sociodemographic factors associated with maternal non-use of ANC services, in CAR, MICS 2018/19 (n=7083)

Figure 1: the prevalence of maternal use of antenatal care by number of visits, in Central African Republic

References