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 Table of Contents  
Year : 2017  |  Volume : 24  |  Issue : 2  |  Page : 67-74

Factors associated with antenatal care services utilisation patterns amongst reproductive age women in Benin Republic: An analysis of 2011/2012 benin republic's demographic and health survey data

1 Department of Reproductive Health, Pan African University Institute of Life and Earth Sciences, University of Ibadan, Ibadan, Nigeria
2 Department of Obstetrics and Gynaecology, University College Hospital, University of Ibadan, Ibadan, Nigeria

Date of Web Publication24-Jul-2017

Correspondence Address:
Justin Dansou
Department of Reproductive Health, Pan African University Institute of Life and Earth Sciences, University of Ibadan, Ibadan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_16_17

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Background: High maternal and neonatal mortality persist in Benin Republic despite recent improvements. Numerous women and newborns continue to suffer preventable deaths. Although factors associated with the attendance of at least one antenatal care (ANC) visit are well documented, there is little evidence on factors related to compliance with World Health Organization (WHO) recommended four ANC visits. The present study determined the extent to which reproductive age mothers received the ANC check-ups at a health facility focussing on the WHO-recommended regimen. Methods: We examined factors related to ANC services utilisation patterns amongst 8701 women recruited in the 2011/2012 Benin Demographic and Health Survey data using multinomial logistic regression. Results: The percentage of mothers with full ANC attendance was 59.56%, 27.61% received less than 4 visits and 12.84% had never attended ANC services. Results showed that out of 13 variables assessed, only the place of residence was not associated with ANC seeking. Amongst significant variables, household wealth index, female education and desire for pregnancy were the most important factors related to ANC services seeking, especially for the achievement of WHO recommended four ANC visits. The relative risk ratio of ANC attendance, for the achievement of WHO recommended four ANC regimens was high amongst mothers from economically well-off households (adjusted relative risk ratio [aRRR] for richest women = 10.6, 95% confidence interval [CI]: 6.16–18.33), educated women (aRRR for primary level = 4.34, 95% CI: 3.00–6.27) and those with desired pregnancies (aRRR = 3.4, 95% CI: 2.58–4.48). Conclusion: To achieve WHO-recommended minimum four ANC visits in Benin Republic, our findings suggest the need to financially support the most economically disadvantaged pregnant women and their families during pregnancy, advocate for reducing unmet needs for family planning, strengthen girls' education, especially by maintaining them in school till completion of at least the secondary school.

Keywords: Antenatal care, Benin Republic, DHS, World Health Organization recommended ANC visits

How to cite this article:
Dansou J, Adekunle AO, Arowojolu AO. Factors associated with antenatal care services utilisation patterns amongst reproductive age women in Benin Republic: An analysis of 2011/2012 benin republic's demographic and health survey data. Niger Postgrad Med J 2017;24:67-74

How to cite this URL:
Dansou J, Adekunle AO, Arowojolu AO. Factors associated with antenatal care services utilisation patterns amongst reproductive age women in Benin Republic: An analysis of 2011/2012 benin republic's demographic and health survey data. Niger Postgrad Med J [serial online] 2017 [cited 2021 Jul 30];24:67-74. Available from: https://www.npmj.org/text.asp?2017/24/2/67/211455

  Introduction Top

Maternal and child mortality has dropped nearly 50% since the 1990s [1],[2] where the approximate global lifetime risk of maternal death fell from 1 in 73 in 1990 to 1 in 180 in 2015.[3] Despite these progresses, women continue to die unnecessarily every day from largely preventable causes during childbirth. In 2013, every minute and a half, a woman dies from complications of pregnancy or childbirth [1],[3] and sub-Saharan Africa remains the most disadvantaged. Amongst maternal deaths recorded worldwide in 2015, about 99% occurred in developing countries where sub-Saharan Africa alone accounts for roughly 66%.[3] In addition, stillbirth rates have not measurably changed over Millennium Development Goals (MDGs) time [1] and thousands of newborns still suffer preventable deaths. Stillbirth rate has declined globally from 24.7 in 2000 to 18.4 in 2015 wherein only 2015 about 2.6 million babies were stillborn and low- and middle-income countries alone accounted for roughly 98% of stillbirths.[4] Thus, maternal and newborn mortality remains a major public health issue in developing countries, particularly those in Sub-Saharan Africa [5] and remains one of the key indicators of the Sustainable Development Goals set for the continuation of the unfinished business of MDGs time. The use of maternal health services is revealed to be amongst the leading means to reduce the risks of maternal and newborn morbidity and mortality.[6] Thereby, the World Health Organization (WHO) promotes basic antenatal care (ANC) in response to maternal and newborn preventable deaths. Good care during pregnancy is important for the development of the mother and the unborn baby. It links the woman and her family with the formal health system and facilitates future health services attendance.[7],[8] Although the new model of the WHO recommendations on antenatal care for a positive pregnancy experience released in 2016 recommends at least eight contacts, the present study relied on the old WHO guidelines released in 2013 recommending at least four visits. This choice is driven by the fact that data used in this study were collected since 2011–2012. In addition, Benin Republic belongs to countries relying on WHO guidelines as a model on antenatal care. The four-visit ANC model outlined in the old WHO clinical guidelines encompass: first visit, between 8 and 12 weeks; second visit, within 24–26 weeks; third visit, at 32 weeks and the fourth visit, within 36–38 weeks.[8] Research showed that achieving the recommended four ANC visits at 90% coverage rate could help save about 37%–71% of newborns' deaths [9] and up to 67% of sub-Saharan Africa's newborns' deaths could be prevented by high coverage of care.[10] On the other hand, good ANC helps lower maternal deaths occurring during pregnancies [11] and helps identify women subjected to female genital mutilation discovered as a key factor behind complications during childbirth.[12]

Despite the mounting global investment and commitment in improving maternal and neonatal survival, inequities in ANC attendance persist at several levels. While coverage of at least one ANC visit has been shown relatively high in Africa,[13] coverage of the four recommended focussed visits is much lower and not routinely tracked.[14] Some studies provide strong evidence that the odds for ANC coverage is lower amongst women from household with poor wealth quintiles, less/non-educated,[8],[15],[16],[17] living in rural areas [8],[17] and having problem in getting permission to visit health facility.[16] For instance in Ghana, in 49.2%, 16.2% and 12.4% of cases, in which women said they were unable to access maternal health services during their last pregnancy, husbands, mothers-in-law and husband plus mothers-in-law, respectively, made the decision.[15] In Nigeria, the odds ratio for ANC attendance increases with improvement in female education (primary level odds ratio [OR] = 1.8 standard error = 0.30, secondary OR 2.01 standard error = 0.43 and post-secondary OR = 5.03 standard error = 2.64) and with increase in household income (poor OR = 1.53 standard error = 0.27, medium OR = 2.48 standard error = 0.48, rich OR = 3.76 standard error = 0.87 and very rich OR = 5.86 standard error = 1.69).[17] Some studies provide strong evidence of the link between some of pregnancy-related characteristics such as birth rank and birth interval and neonatal mortality.[18],[19] Short birth intervals are known to have negative effects on pregnancy outcomes.[20] Elsewhere, evidences indicate the link between family/community involvement and ANC services utilisation [7],[8],[20] while a study pointed out the role of sociocultural factors.[15] In Ghana, women in predominantly Islam areas appeared to be more limited in their ability to participate in reproductive health decision-making.[15] High coverage of ANC in addition to its benefits during pregnancy [8] remains an important determinant for postnatal care check-ups.[7] Exposure to mass media, especially to locally driven mass media campaign is shown to have strong impact on health services utilisation.[6]

High maternal and child mortality persists in Benin Republic. The Maternal Mortality Estimation Inter-Agency Group, recently, established that Benin Republic did not make sufficient progress towards achieving MDG 5A (Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio [MMR]). MMR estimated at 576 maternal deaths for 100,000 live births in 1990 had declined to about 405 deaths for 100,000 live births in 2015 with an average annual decrease of 1.4%.[3] About 1 out of 10 (0.9%) girls gives birth between 15 and 19 years old.[21] Benin belongs to countries with high fertility where the population will still be growing until 2030s [22] in spite of recent decline in fertility. The average births per reproductive age (15–49 years) women estimated at 5.8 in 2000 has declined to 4.9 in 2015. The persistence of customs and traditions, especially in case of fertility accounts for high fertility amongst Beninese women. In response to the persistence of high maternal and infant mortality, several actions and interventions have been noticed. For example, through the Decree number 2008–70 of 22 December 2008, the government of Benin Republic has set free caesarian section in public hospitals, private hospitals and confessional and associative hospitals approved by the government.[23]

Although factors associated with the attendance of at least one ANC visits are well documented, up to date, and in Benin Republic, especially, there is little evidence on factors behind compliance with WHO-recommended minimum four ANC visits during pregnancy. The present study aims to investigate factors related to ANC services utilisation patterns amongst reproductive age women who have completed at least a pregnancy within the preceding 5 years of 2011/2012 Benin Demographic and Health Survey (BDHS). It determines the extent to which these mothers received the WHO-recommended four ANC visits at a health facility and also attempts to identify factors related to non-completion of WHO-recommended regimen. Such understanding can help inform policymakers (Ministry of Health, Ministry of Transport and Public Works, etc.) in the formulation of national and local policies and programmes to increase ANC services utilisation rates, with the ultimate goal of reducing preventable maternal and newborn deaths taking place during pregnancy, at the delivery time and beyond.

  Data and Methods Top

Data source

Secondary data from the fourth BDHS conducted in 2011–2012 were used for the study. Using a nationally representative sample, the Measure DHS collects data on reproductive age women (15–49 years) including reproduction. The sample for this study included mothers who had completed at least a pregnancy within the 5 years preceding the survey. A total of 16,599 women were interviewed at the survey, whereas 9110 were eligible for the current study. After cleaning, analyses were limited to 8701 mothers. For each mother, proportions were calculated regarding whether she attended <4 ANC visits, at least 4 ANC visits, or no ANC visit within the pregnancy period of her last childbirth within the 5 years preceding the survey. Majority of mothers (87.5%) attended at least one antenatal visit and 12.5% attended no antenatal visit while slightly more than half (56.9%) attended the WHO-recommended four ANC visits.

Outcome variable

The outcome of this study was utilisation of ANC services during pregnancy at a health facility. Response was coded 1 if a woman had never attended ANC visits, 2 if she received <4 ANC check-ups and 3 if she achieved WHO-recommended minimum four ANC visits. Women who did not provide a valid answer ('don't know' category) were dropped out from the sample before analyses.

Independent variables

Independent variables were selected based on the literature and their availability in our data. They were age group, educational attainment, occupation, religion, ethnic groups, household wealth quintile, place of residence, rank of pregnancy, desire for pregnancy, main decision maker about mother's/children's health and area of residence. With regard to the area of residence, it was based on the subnational division of the country encompassing 12 different areas usually pairs combined, namely, Atacora/Donga, Atlantique/Littoral, Borgou/Alibori, Mono/Couffo, Oueme/Plateau and Zou/Collines. However, in this study, the Littoral encompassed with only one commune that of Cotonou, entirely urbanised, is dissociated from Atlantique/Littoral because of its particular socio-geographic and socio-economic profile. Three main religious groups were distinguished: Christian (Catholic, Methodist, other Protestant, Celeste and other Christian), Muslim (Islam) and Traditional (Vodoun and other traditional). Eight ethnic groups were recorded in the data. In this study, six groups were considered: Adja, Bariba, Betamaribe, Fon, Yoruba and other ethnic (Yoa, Dendi and other ethnic). The combination of Yoa and Dendi with other ethnic was driven by their low level of representativeness and their geographic proximity.

An indicator of health facility accessibility level, based on geographical, financial and cultural accessibility such as distance to health facility, getting money needed to go to health facility and getting permission to go was created using principal component analysis (PCA) methods to analyse the extent to which the distance to the nearest health facility, financial means and getting verbal permission were barriers to seeking health services during pregnancy period. Each one of the three input variables had two categories: big problem and not big problem corresponding to the perception of respondents regarding each question during the survey. The outcome indicator (named 'accessibility') was grouped into two categories (big problem and not big problem). Furthermore, an indicator of mass media exposure, based on frequency of access to the media such as radio, television and newspaper/magazine was created using PCA methods. The outcome indicator (mass media's level of access) was grouped into three categories (lower access, middle access and higher access). Stata PCA command (pca) without weighting was used.

Statistical analysis and time of realisation

Two levels of analysis were performed. Univariate analysis was involved to perform percentage distribution of study population by selected variables. At multivariable level, multinomial logistic regression was used to calculate the measures of association (adjusted relative risk ratio [RRR]) between each of the independent variables and the likelihood of mothers seeking ANC services. Differences were tested for significance at a 5% level. Analyses were completed using the STATA 12.0 (www.stata.com) software.

This study was first prepared between December 2015 and May 2016 and presented (oral presentation) at the 5th ISIbalo Conference of African Young Statisticians (13–17 June 2016) held in Saint George Hotel, Pretoria, South Africa. The manuscript was revised and completed after the conference in December 2016.

Ethical considerations

The International Review Board of Macro International and the 'Comité National d'Ethique pour la Recherche en Santé du Benin' have all approved the Benin's fourth DHS's tools before the survey was conducted. Participation in the DHS was entirely voluntary, and participants signed an informed consent form preceding the interview.[24] DHS data are freely attainable through measured DHS website. There was no need for ethical approval before using DHS data. To access the data from DHS MEASURE website, a written request was submitted to DHS MACRO and permission was granted to use the data.

  Results Top

Sample characteristics

The average age of the mothers included in this study was 29.3 ± 0.07 years. Most mothers (73.1%) did not have any formal education, about two-third (62.9%) resided in the rural area whereas 45.2% had a low access to mass media. There were eight ethnic groups represented in the sample, predominantly Fon (41.6%) and about half (52.8%) were Christian. About one out of five (20.5%) newborns recently delivered was undesired and half of mothers (51.5%) were between their second and fourth childbearing. About half of mothers (49.9%) perceived accessibility to health facility as a big problem. In most cases (88.4%), decisions regarding mother and her children's health were made jointly by mothers and their partners or with someone else [Table 1].
Table 1: Sample distribution and utilisation of antenatal care distribution (n=8701)

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Determinants of antenatal care services utilisation

Only one of the 13 variables assessed was not statistically associated with ANC services seeking. It was 'place of residence'. Regardless of the level of achievement (less than recommended 4 visits or at least 4), the aRRR of ANC attendance was higher amongst educated women, Muslim and Christian women, women living in wealthier household, women with desired pregnancies, women with fifth or above pregnancies, women using mass media and women living in areas such as Atacora/Donga, Oueme/Plateau, Zou/Collines and Atlantique. It was lower amongst women from Bariba and Yoruba ethnic groups and older women (aged 30 years or above).

It was further discovered that 3 out of the 12 factors behind ANC services seeking, namely, household wealth quintile, female education and desire for pregnancy were the most important factors with greater impact on ANC services utilisation patterns. Improving household's income or female education increases women's chances to receive ANC services specially to achieve the WHO-recommended four ANC visits. Similar results with desired pregnancies were found.

Relative to the poorest women, the richest ones were about 3 times (aRRR = 2.9, 95% confidence interval [CI]: 1.65–5.13) more likely to receive <4 WHO recommended ANC visits and about 11 times (aRRR = 10.63, 95% CI: 6.16–18.33) more likely to achieve the WHO-recommended minimum 4 ANC visits. The relationship between this variable and ANC attendance (regardless of the level of ANC visits achievement) was positive and linear. Compared to uneducated women, those with primary level were about 3 times (aRRR = 3.02, 95% CI: 2.07–4.41) more likely to receive <4 ANC visits, and about 4 times (aRRR = 4.34, 95% CI: 3.00–6.27) more likely to receive at least four ANC visits. Mothers with desired pregnancies were more likely to attend frequent ANC services relative to those with no desire for pregnancy. They were 2.92 times (aRRR = 2.92, 95% CI 2.19–3.90) more likely to receive <4 ANC visits and 3.40 times (aRRR = 3.40, 95% CI 2.58–4.48) more likely to receive at least four ANC visits.

To a lesser extent, the influence of some covariates pertaining to female occupation, religious background and the main decision-maker in case of health issues seems to be similar to those of the previous three factors (household wealth quintiles, female education and desire for pregnancy). When health decisions were jointly made by respondent and her partner or someone else, women had a more relative risk to attend ANC services, especially more likely to achieve WHO-recommended regimen. The relative risk to meet WHO-recommended four ANC visits was higher amongst women working as domestic and those from Christian religion [Table 2].
Table 2: Adjusted relative risk ratio and 95% confidence interval of the likelihood to attend antenatal care services (n=8701)

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[Table 3] presents the distribution of significant factors in order of importance. The hierarchy was based on the relative contribution of each significant factor to the total LR Chi-squared accounted by all significant factors. Amongst the 12 significant factors, household wealth quintiles, female education and desire for pregnancy were the top three important factors contributing more than half (51.8%) of the total LR Chi-squared.
Table 3: Hierarchy of significant factors behind antenatal care services seeking

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  Discussion Top

In agreement with past studies,[15],[16],[17] our findings showed that mothers from households with low wealth status, those without formal education were less likely to utilise ANC services. In many sub-Saharan African countries, financial hardships on the one hand and the cost of medical treatments on the other hand are amongst the leading reasons preventing people from modern health systems utilisation. The cost of medical treatments is also amongst the reasons for self-medication and the recourse to occult practices by people in Benin Republic.[23] Thus, some studies suggest that replacing health services user fees with alternative financing mechanisms should be seen as an important step towards improving access to and utilisation of health services amongst pregnant women.[8] Such recommendation may increase health services uptake, especially ANC services ones amongst the poor. Evidence from South Africa outlined that ANC consultations increased by 15% the years following the removal of user fees on all primary healthcare services.[2] Effective antenatal care requires, amongst other, that the health system ensures that sufficient skilled attendants are recruited and deployed to be able to provide all women with quality ANC.[25] This requirement is challenging in this study context. Benin's health system encounters issues of lack of skilled health workers.[26]

Empirical study showed that family and community membership constitutes a major determinant in access to ANC services [15],[27] as reported by our study. Some studies argued that mothers generally do not have the power to make decisions.[16] Thus, studies suggest that interventions to improve women's use of maternity services should move beyond individual women to target different stakeholders at multiple levels including husbands, mothers-in-law,[15],[25] family and community, too, for effective antenatal care.[25] Exposition to mass media such as listening to radio, watching TV and reading newspapers is found to be a significant factor influencing ANC services utilisation as reported elsewhere.[6]

Findings from this study support the need to take a good look at accessibility issues (geographical, financial and cultural) as recommended by WHO experts.[25] Past studies [28],[29] also reported similar results. Ethnicity and to a lesser extent, religion, had a significant influence on ANC services utilisation in the study area. Perhaps, the persistence of underlying cultural beliefs and value systems continue to shape ANC services uptake amongst pregnant women in Benin Republic. Ethnicity and religious background differences in ANC attendance were also reported in Ghana.[15] Findings from a study in Nigeria reported that living in an urban area increases the odds of ANC services utilisation.[17] Surprisingly, our findings failed to support such result. However, spatial variations (across areas) in ANC services uptake exist in Benin Republic.

Farming mothers are disadvantaged at ANC services utilisation. This could be explained by the way agriculture is practised and the features of majority of people exercising it in this study's context. Finally, this study's findings showed that women with higher pregnancy order (fifth or above) were more likely to use ANC services. Maybe, mothers are aware of the high maternal/newborn mortality risk affecting high-rank order birth. Some studies have provided evidences supporting the link between under five mortality risk and birth order.[20],[30]

Potential study limitations

In additional to memory issues affecting such events, the subjectivity of some questions constitutes limitations of the study. Mothers' and other assets used in determining the level of accessibility using PCA methods were subjective. In addition to the subjectivity, some variables were not so accurate. We do not know whether geographical barriers to health facility utilisation were in terms of practicability of routes or distance from health facility. Indeed, the real distance to health facility or time to reach the health facility was not available. Likewise, the real state of routes was not captured at the survey. As such, it was not possible to access with accuracy how the distance and the time travel from household to the nearest health facility and the state of routes affected the ANC attendance. Furthermore, questions pertaining to financial and cultural barriers to health facility utilisation were subjective and inaccurate. It was not possible to assess with accuracy how financial hardship prevents women from ANC attendance. It was not also possible to know whether permission issues to get to health facility were from partners or other family members such as mother-in-laws.

  Conclusion and Implications Top

The current study examined factors behind ANC services utilisation patterns amongst reproductive age women using Data from 2011/2012 BDHS. It determined the extent to which those mothers received the WHO-recommended four ANC visits during the pregnancy of their youngest children at a health facility. It also identified factors behind non-completion of WHO-recommended four ANC visits. Such understanding is helpful in identifying possible reasons for use and non-use. While this study illuminates such reasons, further research, especially qualitative one is needed for better understanding of some differences such as those relating to sociocultural factors (ethnicity and religion). Such study will help understand underlying cultural beliefs and value systems preventing pregnant women from attending ANC services. However, it was further discovered that three factors, namely, household wealth quintile, female education and desire for pregnancy play key role in ANC attendance, especially for the achievement of the WHO-recommended minimum four ANC visits. Thus, to achieve WHO-recommended minimum four ANC visits in Benin Republic, our findings suggest the need to advise (counselling and education) and financially support pregnant women and their family during pregnancy. Promoting similar actions of that of the caesarian section which was set free, for ANC services will help increase ANC services utilisation amongst pregnant women, especially amongst women from household with low wealth status. There is a need to fight for reducing unmet needs for family planning and to strengthen girls' education, especially by maintaining them in school till completion at least the secondary school.


The first draft of this work was presented (oral presentation) at the 5th ISIbalo Conference of African Young Statisticians (13–17 June 2016) held in Pretoria, South Africa. We are truly grateful to the conference organisers. Our sincere thanks go to all participants who helped us improved the manuscript through their comments.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]

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