Abstract
BackgroundPersisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all. Sub-national decision-makers mandated to deliver health services play a central role in advancing equity but require appropriate evidence to craft effective responses. We use spatial analyses to identify locally-relevant barriers to access using sub-national data from rural areas in Jimma Zone, Ethiopia.MethodsCross-sectional data from 3727 households, in three districts, collected at baseline in a cluster randomized controlled trial were analysed using geographically-weighted regressions. These models help to quantify associations within women’s proximal contexts by generating local parameter estimates. Data subsets, representing an empirically-identified scale for neighbourhood, were used. Local associations between outcomes (antenatal, delivery, and postnatal care use) and potential explanatory factors at individual-level (ex: health information source), interpersonal-level (ex: companion support availability) and health service-levels (ex: nearby health facility type) were modelled. Statistically significant local odds ratios were mapped to demonstrate how relevance and magnitude of associations between various explanatory factors and service outcomes change depending on locality.ResultsSignificant spatial variability in relationships between all services and their explanatory factors (p < 0.001) was detected, apart from the association between delivery care and women’s decision-making involvement (p = 0.124). Local models helped to pinpoint factors, such as danger sign awareness, that were relevant for some localities but not others. Among factors with more widespread influence, such as that of prior service use, variation in estimate magnitudes between localities was uncovered. Prominence of factors also differed between services; companion support, for example, had wider influence for delivery than postnatal care. No significant local associations with postnatal care use were detected for some factors, including wealth and decision involvement, at the selected neighbourhood scale.ConclusionsSpatial variability in service use associations means that the relative importance of explanatory factors changes with locality. These differences have important implications for the design of equity-oriented and responsive health systems. Reductions in within-country disparities are also unlikely if uniform solutions are applied to heterogeneous contexts. Multi-scale models, accommodating factor-specific neighbourhood scaling, may help to improve estimated local associations.
Highlights
Persisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all
Spatial variability in service use associations means that the relative importance of explanatory factors changes with locality
While the majority of women were aware of at least one danger sign associated with pregnancy as well as birth, almost 60% were unaware of postpartum danger signs
Summary
Persisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all. Policies to reduce maternal and infant mortality often target improving utilization of essential maternal health services including antenatal, delivery, and postnatal care (PNC). Linking women and their newborns to care provides opportunities to detect and manage potential complications early on [1]. Reported use of these essential services has been steadily increasing in low- and middleincome countries over the last few decades [2, 3]. In order to meet Sustainable Development Goal targets 3.1 and 3.2, which tackle maternal and child mortality [8], variation in service use at sub-national levels needs to be addressed to ensure equitable progress. Understanding how local contexts change the prominence of factors affecting use is necessary to create policy strategies that are responsive to local needs and make effective use of resources
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