Factors Associated with Utilization of Postnatal Care Services in Mali, West Africa

Background

The postnatal period is the first six weeks after delivery within which the return of the reproductive organs to their normal non-pregnant state occurs.¹ Generally, postnatal care (PNC) is provided to women and their babies within 42 days after delivery.² The World Health Organization³ recommends that after an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. On the other hand, if birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48-72 hours), between 7-14 days after birth, and six weeks after birth.⁴ PNC is essential to both mothers and their babies. It is widely recognized as one of the most effective ways of preventing and managing physical and mental disabilities that occur during the postpartum period.^3,5,6 Thus, lack of PNC service could result in poor health outcomes for both mother and child.⁷

Despite the importance of PNC, it seems to be neglected in some low- and middle-income countries especially in Africa, where a large number of women do not have access to PNC services.⁶ For instance, in rural Tanzania, Mohan et al.⁸ revealed that less than one in four women reported using PNC. Correspondingly, in Uganda, a study that used the 2016 Uganda Demographic and Health Survey revealed that only 50% of women reported having used PNC.⁹ In Zambia, the prevalence of PNC was reported to be 55%.¹⁰ The story is not different in other sub-Saharan African countries such as Ghana,¹¹ Nigeria,^12,13 Ethiopia,¹⁴ Kenya,⁷ and Malawi.¹⁵ Consequently, a considerable number of women in sub-Saharan Africa (SSA) die of pregnancy-related deaths,¹⁶ most of which result from postpartum hemorrhage.¹⁷ Besides, SSA records one of the highest neonatal mortality rates globally with 28 deaths per 1,000 live births.¹⁸

Previous research has noted the need for further research on increasing access and utilization of postnatal care services, especially in resource-poor settings.¹⁹ Some studies conducted in Ghana,^20,21 Nigeria,^12,22,23 Ethiopia,^4,19,24,25 Kenya,⁷ Tanzania,^8,26 Uganda,⁹ Zambia,¹⁰ and Rwanda²⁷ have revealed the determinants of postnatal care services utilization. These studies identified individual (mother's age, educational level, marital status, religion, etc.), household (decision-making capacity for healthcare, wealth quintile and the sex of the head of household) and community-level factors (type of place of residence region, community literacy level, and community socio-economic status) as predictors of postnatal care services utilization.

In Mali, about 31% of maternal deaths occur in the postpartum period.¹⁶ Correspondingly, Mali records a high infant mortality rate (54 deaths per 1000 live births), with most of the deaths occurring in the first month of life.²⁸ Despite the high maternal deaths 562 deaths per 100,000 live births in 2017, compared to the global maternal mortality ratio of 211 per 100,000 live births, PNC utilization in Mali is low.^29,30

Objectives of the Study

In the present study, we investigate factors associated with utilization of postnatal care services in Mali.

Specific Hypothesis

This study is guided by the hypothesis that individual, household and community level factors are associated with PNC utilization in Mali.

Study Variables

The study utilized data from the 2018 Mali Demographic and Health Survey. Specifically the data was from the women's file. The DHS is a nationally representative survey that is conducted in over 85 low- and middle-income countries globally. The survey employs a two-stage stratified sampling technique, which makes the data nationally representative. A total of 5,778 women who had complete information on all the variables of interest were included in our study.

The outcome variable for the study was PNC check-up. It was derived from the question, “Did [NAME] go for postnatal checks within 2 months?” The responses were “Yes”, “No”, and “Don't know”. However, only women who provided definite responses (either “Yes” or “No”) were included in the study, where “No”=0 and “Yes”=l. The study used sixteen (16) independent variables. These variables were considered in our study principally because of their statistically significant relationship with PNC utilization in previous studies.^{10,12,21,22,23} These variables were grouped into individual variables, household variables, and community-level variables. The individual variables included mother's age, educational level, educational level of the mother's partner, marital status, religion, parity, health insurance subscription, employment status, and exposure to mass media. The household variables included decision-making capacity for healthcare, wealth quintile, and the sex of the head of household, while the community-level variables included place of residence, region, community literacy level, and community socio-economic status.

Statistical Analysis

The data were analyzed with Stata version 14.2. The analysis was done in three steps. The first step was the computation of the prevalence of postnatal care in Mali. The second step was a bivariate analysis that calculated the prevalence and proportions of postnatal care across the independent variables with their significance levels. Statistical significance was set at a p-value less than 0.20. To check for a high correlation among the explanatory variables, a test for multicollinearity was carried out using the variance inflation factor (VIF) and the results showed no evidence of high collinearity (Mean VIF= 1.79, Maximum VIF=4.03,and Minimum VIF=1.01). Variables that showed statistical significance in the bivariate analysis were further analyzed using the multilevel logistic regression. In terms of the modelling, four models, comprising the empty model (Model 0), Model 1, Model 2, and Model 3 were fitted hierarchically. Model 0 showed the variance in PNC attributed to the clusters without the explanatory variables. Model 1 contained the individual level factors only, while the household level factors were added to the individual level factors in Model 2. Finally, Model 3 was the complete model that had the individual, household, and community level factors. Adjusted odds ratio (aOR) and associated 95% confidence intervals (CIs) were presented for all the models apart from model 0. We applied sample weight (v005/1,000,000) to correct for over- and under-sampling, and we used the SVY command to account for the complex survey design and generalizability of the findings.

Ethical Approval

This was a secondary analysis of data which did not require further approval since the data is freely available in the public domain. However, the source of data (DHS) reports that ethical clearance was obtained from the Ethics Committee of ORC Macro Inc. as well as Ethics Boards and Ministry of Health of Mali. The DHS is guided by the standards for ensuring the protection of respondents' privacy. Inner City Fund (ICF) International ensured that the survey complies with the U.S. Department of Health and Human Services regulations for the respect of human subjects.

Socio-demographic Characteristics

The results indicate that postnatal care services utilization was high among women aged 40-44 (28.3%), those with secondary/higher education (28.4%) and whose partners had secondary/higher education (33%), cohabiting women (31.2%), Muslims (25.6%), those with one birth (27.2%), those who were covered by National Health Insurance Scheme (48.9%), those who were working (26.5%), and those who were exposed to mass media (26.5%). Furthermore, postnatal care services utilization was high among women in female-headed households (26.4%), those in the richest wealth quintile (34.6%), those who lived in urban areas (33%), those in the Mopti region (50.8%), those in communities with high educational level (33.7%), and those who lived in communities with high socio-economic status (34.1%). At a p-value of 0.20, all the background characteristics of women (except age, marital status, and sex of household head) were significant (Table 1).

Prevalence of Postnatal Care Services Utilization Among Childbearing Women in Mali

The results show that a little over a quarter (25.18%) of childbearing women in Mali utilized postnatal care services (Figure 1).

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Figure 1:

Prevalence of postnatal care services utilization among childbearing women in Mali

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Factors Associated with Postnatal Care Services Utilization Among Childbearing Women in Mali

Women with no formal education (aOR= 1.28, 95% CI= 1.02-1.62) and those with primary level of education (aOR=l.38, 95% CI=1.06-1.81) had higher odds of postnatal care uptake, compared to those with secondary/higher education. On the contrary, postnatal care services utilization was lower among women who were not covered by health insurance (aOR=0.63, 95% CI=0.46-0.88), those who were not working (aOR=0.82, 95% CI=0.70-0.96), and those who were not exposed to mass media (aOR=0.80, 95% CI=0.70- 0.93), compared to those who were covered by health insurance, those who were working, and those who were exposed to mass media, respectively. Similarly, compared to women in the Mopti region, women in all other regions were less likely to utilize postnatal care services. Postnatal care services utilization was also lower among women in communities with low educational level (aOR = 0.42, 95% CI=0.27-0.66) and those in communities with medium socio-economic status (aOR=0.59, 95% CI=0.36-0.99) compared to those in high educational level and socio-economic status communities, respectively (Table 2).

Strengths and Limitations of the study

The main strength of the study lies in its use of a nationally representative data. As such, generalizability of the findings to women in the entire nation is guaranteed. Relatedly, the findings could be a reflection of the current state of affairs, since the study used the most recent version of the Mali Demographic and Health Survey. Moreover, the survey relied on best data collection methods, featuring highly experienced field assistants. Despite these strengths, it is prudent for the findings to be seen in the light of certain limitations. First, the study employed a cross-sectional study design, which prevents us from making causal inferences among the studied variables. Additionally, the study suffers from recall biases that characterize demographic and health survey data.

Compliance with Ethical Standards