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  • Zacharie Tsala Dimbuene (a1) (a2) (a3), Joshua Amo-Adjei (a1) (a4), Dickson Amugsi (a1), Joyce Mumah (a1), Chimaraoke O. Izugbara (a1) and Donatien Beguy (a1)...

There is an abundant literature on the relationship between women’s education and maternal and child outcomes, including antenatal and postnatal care, onset of antenatal care and skilled birth attendance. However, few studies have adopted the ‘equity’ lens, despite increasing evidence that inequities between rich and poor are increasing although maternal and child mortality is declining. This study examined the differential effects of women’s education within different socioeconomic strata in Africa. The most recent Demographic and Health Surveys (DHS) conducted in the Democratic Republic of the Congo, Egypt, Ghana, Nigeria and Zimbabwe were used. In each country, the original sample was stratified into three socioeconomic groups: poor, middle and rich. For each maternal health service utilization variable, the gross and net effects of women’s education, controlling for age, parity, religion, marital status, health insurance, access to health facilities, partner’s education and current place of residence, were estimated using logistic regression, taking into account the complex sampling design of the DHS. The findings revealed country-specific variations in maternal health service utilization, and for most indicators there was a clear gradient among socioeconomic strata: women living in better-off households exhibited greater access to, and utilization of, maternal health services. Multivariate analyses revealed that women’s education had a positive association with type of antenatal care provider, timing and frequency of antenatal care visits, place of delivery and presence of a skilled birth attendant at delivery. Many other factors were found to be significantly associated with maternal health service utilization. For instance, parity had a negative and significant association with timing of first antenatal care visit. Likewise, partner’s education was positively and statistically associated with timing of first antenatal care visit. It is argued that an over-generalization of the association between women’s education and maternal health service utilization can be misleading. Efforts to improve maternal health service utilization in Africa must adopt an ‘equity’ approach, taking into account the specific needs of sub-populations.

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Ahmed S., Creanga A. A., Gillespie D. G. & Tsui A. O. (2010) Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One 5, e11190.
Alexander G. R. & Kotelchuck M. (2001) Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research. Public Health Reports 116, 306316.
Babalola S. & Fatusi A. (2009) Determinants of use of maternal health services in Nigeria – looking beyond individual and household factors. BMC Pregnancy Childbirth 9, 43.
Bicego G., Boerma J. T. & Ronsmans C. (2002) The effect of AIDS on maternal mortality in Malawi and Zimbabwe. AIDS 16, 10781081.
Caldwell J. C. (1979) Education as a factor in mortality decline: an examination of Nigerian data. Population Studies 33, 395413.
Cleland J. G. & Van Ginneken J. K. (1988) Maternal education and child survival in developing countries: the search for pathways of influence. Social Science & Medicine 27, 13571368.
Corroon M., Speizer I. S., Fotso J.-C., Akiode A., Saad A., Calhoun L. & Irani L. (2014) The role of gender empowerment on reproductive health outcomes in urban Nigeria. Maternal and Child Health Journal 18, 307315.
Countdown Coverage Writing Group (2008) Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet 371, 12471258, doi: 10.1016/S0140-6736(08)60559-0.
Countdown 2008 Equity Analysis Group, Boerma J. T., Bryce J., Kinfu Y., Axelson H. & Victora C. G. (2008) Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries. Lancet 371, 12591267.
Crowe S., Utley M., Costello A. & Pagel C. (2012) How many births in sub-Saharan Africa and South Asia will not be attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy & Childbirth 12, 4.
Dalal K., Shabnam J., Andrews-Chavez J., Martensson L. B. & Timpka T. (2012) Economic empowerment of women and utilization of maternal delivery care in Bangladesh. International Journal of Preventive Medicine 3, 628636.
DeWalt D. A. & Hink A. (2009) Health literacy and child health outcomes: a systematic review of the literature. Pediatrics 124, S265S274.
Dogba M. & Fournier P. (2009) Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature. Human Resources for Health 7, 7.
Elo I. T. (1992) Utilization of maternal health-care services in Peru: the role of women’s education. Health Transition Review 2, 4969.
Ensor T. & Cooper S. (2004) Overcoming barriers to health service access: influencing the demand side. Health Policy and Planning 19, 6979.
Fotso J.-C. & Kuate-Defo B. (2005) Measuring socioeconomic status in health research in developing countries: should we be focusing on households, communities or both? Social Indicators Research 72, 189237.
Fotso J. C., Ezeh A. C. & Essendi H. (2009a) Maternal health in resource-poor urban settings: how does women’s autonomy influence the utilization of obstetric care services? Reproductive Health 6, 9.
Fotso J. C., Ezeh A., Madise N., Ziraba A. & Ogollah R. (2009b) What does access to maternal care mean among the urban poor? Factors associated with use of appropriate maternal health services in the slum settlements of Nairobi, Kenya. Maternal and Child Health Journal 13, 130137.
Friberg I. K., Kinney M. V., Lawn J. E., Kerber K. J., Odubanjo M. O., Bergh A. M. & Nkrumah F. (2010) Sub-Saharan Africa’s mothers, newborns, and children: how many lives could be saved with targeted health interventions? PLoS Medicine 7, e1000295.
Fuchs V. R. (1980) Time Preference and Health: An Exploratory Study. National Bureau of Economic Research, Cambridge, MA, USA.
Gabrysch S. & Campbell O. M. (2009) Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 9, 34.
Ganle J. K., Otupiri E., Parker M. & Fitpatrick R. (2015) Socio-cultural barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition. Internal Journal of Maternal and Child Health 3, 114.
Ganle J. K., Parker M., Fitzpatrick R. & Otupiri E. (2014) Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study. International Journal for Equity in Health 13, 89.
Gebremeskel F., Dibaba Y. & Admassu B. (2015) Timing of first antenatal care attendance and associated factors among pregnant women in Arba Minch Town and Arba Minch District, Gamo Gofa Zone, South Ethiopia. Journal of Environmental and Public Health, ID 971506, doi: 10.1155/2015/971506.
Greenaway E. S., Leon J. & Baker D. P. (2012) Understanding the association between maternal education and use of health services in Ghana: exploring the role of health knowledge. Journal of Biosocial Science 44, 733747.
Grossman M. (2008) The relationship between health and schooling. Eastern Economic Journal 34, 281292.
Hofmeyr G. J., Haws R. A., Bergstrom S., Lee A. C., Okong P., Darmstadt G. L. et al. (2009) Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up? International Journal of Gynaecology and Obstetrics 107 (Supplement 1), S21S44, S44–S25.
Hogan M. C., Foreman K. J., Naghavi M., Ahn S. Y., Wang M., Makela S. M. et al. (2010) Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 375, 16091623.
Kerber K. J., de Graft-Johnson J. E., Bhutta Z. A., Okong P., Starrs A. & Lawn J. E. (2007) Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 370, 13581369.
Kindig D. A., Panzer A. M. & Nielsen-Bohlman L. (2004) Health Literacy: A Prescription to End Confusion: National Academies Press.
Kinney M., Lawn J. & Kerber K. (eds) (2009) Science in Action: Saving the Lives of Africa’s Mothers, Newborns, and Children. Report for the African Academy Science Development Initiative, Cape Town, South Africa. URL:
Kinney M. V., Kerber K. J., Black R. E., Cohen B., Nkrumah F., Coovadia H. et al. (2010) Sub-Saharan Africa’s mothers, newborns, and children: where and why do they die? PLoS Medicine 7, e1000294.
Koblinsky M., Matthews Z., Hussein J., Mavalankar D., Mridha M. K., Anwar I. et al. (2006) Going to scale with professional skilled care. Lancet 368, 13771386.
Lawn J. E., Cousens S. & Zupan J., Team for Lancet Neonatal Survival Steering Team (2005) 4 million neonatal deaths: When? Where? Why? Lancet 365, 891900.
Lawn J. E., Lee A. C., Kinney M., Sibley L., Carlo W. A., Paul V. K. et al. (2009) Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? International Journal of Gynaecology and Obstetrics 107, S5S18, S19.
Levine R. A. & Rowe M. L. (2009) Maternal literacy and child health in less-developed countries: evidence, processes, and limitations. Journal of Developmental and Behavioral Pediatrics 30, 340349.
McGlynn N., Wilk P., Luginaah I., Ryan B. L. & Thind A. (2015) Increased use of recommended maternal health care as a determinant of immunization and appropriate care for fever and diarrhoea in Ghana: an analysis pooling three demographic and health surveys. Health Policy and Planning 30, 895905.
Malqvist M., Lincetto O., Du N. H., Burgess C. & Hoa D. T. (2013) Maternal health care utilization in Viet Nam: increasing ethnic inequity. Bulletin of the World Health Organization 91, 254261.
Moyer C. A., Adongo P. B., Aborigo R. A., Hodgson A., Engmann C. M. & DeVries R. (2014) ‘It’s up to the woman’s people’: How social factors influence facility-based delivery in rural northern Ghana. Maternal and Child Health Journal 18, 109119.
Nutbeam D. (2000) Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 15, 259267.
Ochako R., Fotso J. C., Ikamari L. & Khasakhala A. (2011) Utilization of maternal health services among young women in Kenya: insights from the Kenya Demographic and Health Survey, 2003. BMC Pregnancy Childbirth 11, 1.
Raghupathy S. (1996) Education and the use of maternal health care in Thailand. Social Science & Medicine 43, 459471.
Rai R. K., Singh P. K. & Singh L. (2012) Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Women’s Health Issues 22, e407e414.
Ronsmans C., Etard J. F., Walraven G., Hoj L., Dumont A., de Bernis L. & Kodio B. (2003) Maternal mortality and access to obstetric services in West Africa. Tropical Medicine and International Health 8, 940948.
Sado L., Spaho A. & Hotchkiss D. R. (2014) The influence of women’s empowerment on maternal health care utilization: evidence from Albania. Social Science & Medicine 114, 169177.
Saxena D., Vangani R., Mavalankar D. V. & Thomsen S. (2013) Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data. Global Health Action 6, 19.
Say L. & Raine R. (2007) A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bulletin of the World Health Organization 85, 812819.
Simkhada B., Teijlingen E. R., Porter M. & Simkhada P. (2008) Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. Journal of Advanced Nursing 61, 244260.
Singh L., Rai R. K. & Singh P. K. (2012a) Assessing the utilization of maternal and child health care among married adolescent women: evidence from India. Journal of Biosocial Science 44, 126.
Singh P. K., Rai R. K., Alagarajan M. & Singh L. (2012b) Determinants of maternity care services utilization among married adolescents in rural India. PLoS One 7, e31666.
Sreeramareddy C. T., Sathyanarayana T. N. & Kumar H. N. (2012) Utilization of health care services for childhood morbidity and associated factors in India: a national cross-sectional household survey. PLoS One 7, e51904.
Sreeramareddy C. T., Shankar R. P., Sreekumaran B. V., Subba S. H., Joshi H. S. & Ramachandran U. (2006) Care seeking behaviour for childhood illness – a questionnaire survey in western Nepal. BMC International Health and Human Rights 6, 7.
Tawiah E. (2011) Maternal health care in five sub-Saharan African countries. African Population Studies 25, 125.
Thaddeus S. & Maine D. (1994) Too far to walk: maternal mortality in context. Social Science & Medicine 38, 10911110.
Tsawe M., Moto A., Netshivhera T., Ralesego L., Nyathi C. & Susuman A. S. (2015) Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland. International Journal of Equity in Health 14, 32.
Tsawe M. & Susuman A. S. (2014) Determinants of access to and use of maternal health care services in the Eastern Cape, South Africa: a quantitative and qualitative investigation, BMC Research Notes 7, 723.
UNICEF (2009) State of the World’s Children 2010. UNICEF, New York.
Villar J., Ba’aqeel H., Piaggio G., Lumbiganon P., Miguel Belizan J., Farnot U. et al. (2001) WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 357, 15511564.
WHO (2003) Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities. An Analysis of Trends, Levels and Differentials, 1990–2001. WHO, Geneva, Switzerland.
WHO (2011) Evaluating the Quality of Care for Severe Pregnancy Complications: The WHO Near-Miss Approach for Maternal Health. WHO, Geneva, Switzerland.
WHO, UNICEF, UNFPA, World Bank Group & the United Nations Population Division (2015) Trends in Maternal Mortality: 1990 to 2015 . WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. WHO, Geneva, Switzerland.
Wolter K. M. (2003) Introduction to Variance Estimation. Springer, New York.
Worku A. G., Yalew A. W. & Afework M. F. (2013) Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis. BMC International Health and Human Rights 13, 20.
You D., Jones G., Hill K., Wardlaw T. & Chopra M. (2010) Levels and trends in child mortality, 1990–2009. Lancet 376, 931933.
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Journal of Biosocial Science
  • ISSN: 0021-9320
  • EISSN: 1469-7599
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