Does quality of antenatal care explain rural-urban differentials in use of skilled birth attendants?

Background: About 800 maternal deaths occur each day, with over half in Sub-Sahara-Africa (SSA) alone. Delivery by Skilled-Birth-Attendants (SBAs) is critical to reducing maternal mortality.  Yet, less than half of births in rural SSA are assisted by a SBA. This is usually attributed to poor health service accessibility, but few studies have actually examined the intervening factors. Qualitative studies suggest quality of maternal health services influences use of SBAs, but few quantitative studies have examined this; and fewer have examined the factors that influence the quality of maternal health care women in SSA receive.

Aim: The purpose of this study is to examine the factors that influence quality of antenatal care (ANC) and use of SBAs in SSA; and whether quality of ANC partially mediates the effect of place of residence on use of SBAs.

Methods: The World Health Survey data for Ghana and Burkina Faso are used (N=2,049). The analysis includes logistic regression with mediation and moderation analysis.

Results: Net of other factors, urban residence is positively associated with better ANC quality. Urban residence and ANC quality are both positively associated with use of SBAs – controlling for socioeconomic and other factors. Quality of ANC care explains a significant amount of the rural/urban differential in use of SBAs. 

Implications: Improving basic quality of ANC provided to rural women is a potential approach to bridging the rural/urban difference in use of SBAs in SSA. This may be more feasible in the short term in many SSA countries than improving access.