A multilevel analysis of social determinants of skilled birth attendant utilisation among married and cohabiting women of Madagascar

Ebenezer Kwesi Armah-Ansah; Benedicta Bawa; John Dindas; Eugene Budu; Bright Opoku Ahinkorah; Edward Kwabena Ameyaw

doi:10.1093/inthealth/ihad108

A multilevel analysis of social determinants of skilled birth attendant utilisation among married and cohabiting women of Madagascar

Int Health. 2023 Nov 27:ihad108. doi: 10.1093/inthealth/ihad108. Online ahead of print.

Authors

Ebenezer Kwesi Armah-Ansah^{1

2

3}, Benedicta Bawa⁴, John Dindas⁵, Eugene Budu⁶, Bright Opoku Ahinkorah^{7

8}, Edward Kwabena Ameyaw^{9

10}

Affiliations

¹ Population Dynamics Sexual and Reproductive Health Unit, African Population and Health Research Center, Nairobi, Kenya.
² Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
³ Department of Population and Development, National Research University, Higher School of Economics, Moscow, Russia.
⁴ One Trust Limited, East Legon, Accra, Ghana.
⁵ Department of Public Health and Healthcare, I.M. Scehenov First Moscow State Medical University, Moscow, Russia.
⁶ Korle Bu Teaching Hospital, P.O. Box, 77, Accra, Ghana.
⁷ School of Clinical Medicine, University of New South Wales, Sydney, Australia.
⁸ REMS Consult Limited, Sekondi-Takoradi, Western Region, Ghana.
⁹ Institute of Policy Studies and School of Graduate Studies, Lingnan University, Tuen Mun, Hong Kong.
¹⁰ L & E Research Consult Limited, Wa, Upper West Region, Ghana.

PMID: 38011796
DOI: 10.1093/inthealth/ihad108

Abstract

Background: Maternal mortality ratio (MMR) in Madagascar is 392 deaths per 100 000 live births, and this is a major public health concern. One of the strategies for reducing MMR and achieving target 3.1 of the Sustainable Development Goals (i.e. reducing the global MMR below 70 per 100 000 live births) is the utilisation of skilled birth attendants (SBAs). This analysis examined the prevalence and social determinants of SBA utilisation among married and cohabiting women of Madagascar.

Methods: Data from the 2021 Madagascar Demographic and Health Surveys was analysed on a weighted sample of 6997 married and cohabiting women. A multilevel regression was carried out to determine the social determinants of utilising SBAs. The results are presented as odds ratios (ORs) associated with 95% confidence intervals (CIs) and a p-value <0.05 to determine the significant associations.

Results: The prevalence of SBAs among married and cohabiting women of Madagascar was 64.4% (95% CI 0.62 to 0.68). In model 3 of the multilevel regression, women 35-39 y of age (adjusted OR [aOR] 1.86 [95% CI 1.30 to 2.60]), women with secondary/higher education (aOR 1.67 [95% CI 1.32 to 2.10]), women whose partners had secondary/higher education (aOR 1.58 [95% CI 1.25 to 1.99]), cohabiting women (aOR 1.33 [95% CI 1.07 to 1.65]), women who had four or more antenatal care visits (aOR 2.05 [95% CI 1.79 to 2.35]), female household head (aOR 1.44 [95% CI 1.06 to 1.95]), Muslims (aOR 1.58 [95% CI 0.71 to 3.53]), those of the richest wealth index (aOR 4.32 [95% CI 2.93 to 6.36]) and women who lived in communities with high literacy levels (aOR 2.17 [95% CI 1.57 to 3.00]) had higher odds of utilisation of SBA.

Conclusion: This current analysis revealed low SBA utilisation among married and cohabiting women in Madagascar. The analysis points to the fact that understaffing and inaccessibility of health facilities remain major contributors to the low utilisation of SBAs. The findings call on the government and stakeholders in Madagascar to consider implementing programs that will empower women and focus on disadvantaged groups. These programs could include providing free maternal healthcare services to all pregnant women and intensifying health education programs that target women and their partners with no formal education.

Keywords: Demographic and Health Surveys (DHS); Madagascar; determinants; multilevel analysis; skilled birth attendant; utilisation.