Ethnicity and Maternal Health Care Utilization in Nigeria: the Role of Diversity and Homogeneity In spite of the significant improvements in the health of women worldwide, maternal mortality ratio has remained high in Nigeria as in other developing countries. With an estimated 59,000 maternal deaths annually, Nigeria contributes 10 percent of the world s maternal deaths (Babalola & Fatusi, 2009) indicating that maternal health situation in the country is very poor. The poor maternal health situation in Nigeria suggests that the Millennium Development Goal 5 which seeks to reduce maternal mortality by three quarters by 2015 is not achievable. However, some researchers have linked the high maternal mortality ratios to inaccessibility of health services, lack of functional and effective health care systems and more importantly non-use of modern maternal health care services, including delivery and postnatal care (Kistiana, 2009; Onah, 2006; Midhet et al. 1998). Health facility delivery is an important factor that can influence maternal and neonatal outcomes. For instance, health facility delivery attended to by trained medical personnel has been shown to be associated with maternal and newborn mortality and morbidity rates that are lower than home delivery (Stephenson et al., 2006). For both mothers and newborns, the period after delivery is also very critical; hence postnatal care services enable skilled health professionals to detect postpartum problems and potential complications and provide prompt treatment (Titaley et al. 2010). Despite the importance of these interventions, Nigeria 2008 DHS report indicated that about 38 percent of women delivered in a health facility and more than half (56%) did not receive postnatal care. Besides, there are huge variations in the utilization of these maternal health care services across various regions and ethnic groups in the country. The relationship between ethnic origin and health outcomes is well documented (Babalola & Fatusi, 2009; Wall, 1998; Macbeth and Shetty, 2001; Braun, 2002; Collins, 2004; Culley, 2005; Antai, 2011). However, there is a paucity
of research regarding the role of ethnic diversity and homogeneity in the utilization of maternal health care services. Arguably, ethnic origin of an individual per se does not influence health outcomes, but rather the socio-economic characteristics of ethnic groups (Jatrana, 2003). Ethnic concentration in a particular community can influence a woman s decision to use maternal health care. Therefore understanding the extent to which ethnicity explains differences in maternal health care utilization is important. This study specifically seeks to explore the relationship between ethnicity (ethnic diversity or homogeneity) and the use of maternal health care services (place of delivery and postnatal) care in Nigeria. The study seeks to test the hypothesis that ethnic diversity is positively and significantly associated with place of delivery and postnatal care. Methods The study used a cross sectional data- the 2008 Nigerian Demographic and Health Survey (NDHS). The 2008 NDHS provided information on population and health indicators at the national and state levels. The primary sampling unit (PSU), which is referred to as the cluster was selected from the lists of Enumeration Areas (EAs). Sample for the survey was selected using a stratified two-stage cluster design, made up of 888 clusters; 286 in the urban and 602 in the rural areas (NPC and ICF, 2009). A weighted probability sample of 36,800 households was selected in the survey and a minimum of 950 interviews were completed for each state. For each cluster, a listing of household and mapping was done, and the lists of households were used as the sampling frame for the selection of households in the second stage. Details about the sampling have been discussed elsewhere (NPC &ICF Macro, 2009). The original sample is made up 33,385 women years and 15,486 men aged 15-59 aged 15-49. However, the analytical sample for this study consists of 17542 women for place delivery and 17437 for postnatal care. The analysis was restricted to women 15-49 years old who had had their last birth in the five years preceding the
survey. If women had more than one birth in the reference period, only the last birth was considered. Variables The outcome variables are place of delivery and postnatal care. Place of delivery is a binary variable coded 1 if delivery took place in a health facility and 0 if a woman delivered at home. Postnatal care and is defined as receiving postnatal check from trained medical personnel (doctor, nurse/midwife); and within 41 days after childbirth (NPC & ICF Macro, 2009). Postnatal care is a binary variable coded 1 if postnatal care was received and 0 otherwise. The major explanatory variable is ethnicity. Ethnicity in this study is defined in terms of ethnic concentration within a community. The measures of ethnicity used in the study are constructed from self-reported ethnic origin in the 2008 Nigeria DHS. It is measured as the proportion of women from different ethnic groups within a community (Primary sampling unit). This measure was divided into two quantiles and categorized as diversity and homogeneity. When the concentration of women from different ethnic groups in a community is high it is referred to as ethnic diversity and when the concentration is low, it is referred to as homogeneity. Other independent control variables include maternal age at last birth, education, occupation, women s autonomy, parity, household wealth index, exposure to family planning messages, and distance to health facility. Maternal age is defined as the age of the woman at the birth of the last child in the five years preceding the survey. This is calculated by subtracting the century month code (CMC) of the date of birth of the child from the century month code of the date of birth reported by the respondent. Maternal age is further classified into: 15-24, 25-34 and 35-49 years. Education is defined as the
highest level of education attended by the respondent and categorized as: no education, primary, and secondary or higher. Occupation is measured as the work status of women and was categorized into formal employment (a merger of all professional and none professional white collar jobs) agricultural employment manual workers and unemployed. Women s autonomy is measured as decision making on a woman s own health care. Parity is measured as the number of children ever born and categorized as 1-2, 3-4, 5 or more. Household wealth index is the DHS wealth index measured as a standardized composite variable made up of quintiles. This is determined through Principal Component Analysis (from Factor Analysis) and based on household assets (e.g., type of flooring, water supply, electricity, radio, television, refrigerator, type of vehicle). Each quintile represents a relative measure of a household s socioeconomic status (Rutstein and Johnson, 2004). Exposure to family planning messages was categorized as: Yes and No. Distance to health facility is defined as perceived problem of distance to a health facility and categorized as: not a big problem and a big problem. Statistical analysis Frequencies and cross-tabulations were used to describe the socio-demographic characteristics of women by ethnicity. Sample weights provided in the DHS data were applied for the bivariate analyses. All analysis was done using STATA 11.1 version. Multivariate logistic models were fitted to assess the association between ethnicity (diversity and homogeneity) and the utilization of delivery and postnatal care and to assess the extent to which demographic and socio-economic factors account for the observed ethnic differences in the outcome variables. Logistic regression was used because of the binary nature of the variables of interest. The logistic model for a binary dependent variable and K independent variables (X 1, X 2, X 3,, X K ) (Rogan, 2004) is written as:
Logit p (X) = α + β i X i.. X k Exp (β i ) = Odds ratio for a woman having the outcome i versus not having the outcome i β = Regression coefficient α = Constant A sequence of 2 models was estimated for each of the outcome variables. The first model included only ethnicity. This enabled the assessment of the gross effect of ethnicity on the outcome variables (place of delivery and postnatal care). The second model all the explanatory variables. This model provided estimates of the net effects of ethnicity on place of delivery and postnatal care after controlling for all the relevant set of explanatory variables. Results Descriptive statistics Results show that women in all age categories were evenly distributed in high ethnic diversity and homogeneous areas (Table 1). A significant proportion of high parity and low parity women (55% and 45% respectively) were from areas with a high concentration of women from different ethnic groups. A higher proportion of women from both ethnic diversity and homogeneous communities had no education. More than half (51.3%) of the women who resided in high ethnic diversity communities were employed in the formal sector, whereas 48.7% of the women in homogeneous communities were in formal employment. In high ethnic diversity areas, majority of the women (60.7%) made joint decisions with their husbands regarding their own health care, while 39.3% of
women from areas of low concentration of women from different ethnic groups made joint decisions with their husbands. Women were evenly distributed across wealth quintiles in both ethnic diverse and homogeneous communities. More than half of the women from high ethnic diversity areas were not exposed to family planning messages, while 45.3% that were not exposed resided in homogeneous communities. Table 1 Socio-demographic characteristics of respondents by ethnicity, Nigeria 2008 DHS Variables Ethnicity P-value Maternal age at last birth 15-24 25-34 35-49 Parity 1-2 3-4 5 or more Education No education Primary Secondary/higher Occupation Unemployed Formal employment Agricultural employment Manual workers Women s autonomy (decision making) Wife alone Wife/husband Husband alone/others Household wealth index Poorest Poorer Middle Rich Richest Family planning message exposure No Yes Perceived distance problem Homogeneous 45.4 45.8 45.5 45.4 46.4 45.0 48.5 40.3 45.3 49.2 48.7 26.7 54.1 44.6 39.3 49.9 44.9 42.2 46.2 49.4 46.3 45.3 46.9 Diversity 54.6 54.2 54.5 0.932 54.6 53.6 55.0 0.504 51.5 59.7 54.7 0.033 50.8 51.3 73.3 45.9 0.001 55.4 60.7 50.1 0.001 55.1 57.8 53.8 50.6 53.7 0.387 54.7 53.1
Not a big problem A big problem 47.0 43.3 53.0 56.7 0.083 A significant 43.3% and 56.7% of women who lived in both homogeneous and high ethnic diversity areas respectively reported that distance is a big problem in seeking health care. Table 2 indicates that more than one third of women who resided in both homogeneous and high ethnic diversity communities delivered in a health facility and received skilled postnatal care. Table 2 Percentage distribution of women by ethnicity controlling for place of delivery and postnatal care, Nigeria 2008 DHS Variable Ethnicity Homogeneity Diversity Place of delivery (health facility) 39.9 37.6 Postnatal care (received) 31.5 34.6 Results in Table 3 (Model 1) shows that ethnicity is negatively and significantly associated with place of delivery with women from high ethnic diversity areas less likely to deliver in a health facility compared to women from homogeneous communities. After controlling for other covariates in model 2, results indicate that the effect of ethnic diversity on health facility delivery was not affected by age, parity, education, occupation, a woman s autonomy, household wealth index, exposure to family planning and perceived problem of distance. Living in high ethnic diversity communities significantly decreased the odds of delivering a baby in a health facility net of other factors. Results in Table 3 also show that ethnicity was positively and significantly associated with postnatal care. In model 1, living in high ethnic diversity communities was associated with increased odds of receipt of postnatal care. In model 2, the odds of receiving postnatal care increased and remained significant even after controlling for other explanatory variables.
Table 3 Logistic regression odds ratio of the effects of ethnicity on place of delivery and postnatal care, Nigeria, 2008 DHS Variables Ethnicity Homogeneity Diversity Model 1 Odds ratio (95% CI) 0.88*** (0.82-94) Place of delivery (health facility) Model 2 AOR (95% CI) 0.81*** (0.74-0.88) Model 1 Odds ratio (95% CI) 1.12*** (1.05-1.19) Postnatal care received Model 2 AOR (95% CI) 1.22*** (1.12-1.32) Maternal age at last birth 15-24 25-34 35-49 Parity 1-2 3-4 5 or more Education No education Primary Secondary/higher Occupation Unemployed Formal employment Agricultural employment Manual workers Women s autonomy (decision making) Wife alone Wife/husband Husband alone/others Household wealth index Poorest Poorer Middle Rich Richest Family planning message exposure No Yes Perceived distance problem Not a big problem 1.37*** (1.23-1.54) 1.58*** (1.35-1.85) 0.72*** (0.64-0.80) 0.58*** (0.51-0.68) 2.95*** (2.65-3.28) 5.53*** (4.93-6.20) 1.49*** (1.34-1.66) 1.90*** (1.67-2.17) 1.03 (0.88-1.20) 0.95 (0.81-1.11) 0.66*** (0.52-0.71) 1.83*** (1.58-2.11) 3.41*** (2.95-3.93) 6.67*** (5.72-7.79) 15.23 (12.65-1834) 1.65*** (1.45-1.86) 0.85*** (0.78-0.94) A big problem Log likelihood -6949.8015 R 2 0.352 AOR =Adjusted odds ratio 1.27*** (1.14-1.41) 1.44*** (1.24-1.67) 0.81*** (0.73-0.89) 0.66*** (0.58-0.75) 2.35*** (2.11-2.61) 3.45*** (3.07-3.87) 1.27*** (1.14-1.41) 1.44*** (1.26-1.64) 1.09 (0.94-1.27) 0.98 (0.85-1.14) 0.69*** (0.60-0.80) 2.06*** (1.77-2.40) 3.77*** (3.244.38) 6.29*** (5.35-7.38) 12.86*** (10.72-15.42) 1.49*** (1.33-1.67) 0.68*** (0.62-0.74) -10904.668 0.0005 Significance *p<0.05 **p<0.01*** p<0.001
Discussion The results have demonstrated that ethnic diversity is associated the use of delivery and postnatal care. The finding indicates that the high ethnic effects of ethnic composition of the community on maternal and child health outcomes are complex and sometimes difficult to understand (Boco, 2010). Surprisingly, results indicated that living in communities with a high proportion of women from different ethnic groups was associated with decreased odds of delivering a baby in a health facility. This association, though unexpected, could reflect the heterogeneity and social and ecological settings in Africa (Brockerhoff and Hewett, 1998:5) which are barriers to seeking maternal health care. Conclusion Findings of the study have demonstrated that ethnic diversity was positively and significantly associated with postnatal care. However, the relationship with place of delivery was negative and significant indicating the need for further research to understand the mechanisms in operation. Findings suggest that community interventions aimed at increasing the use of delivery and postnatal care should take into account important characteristics like ethnic heterogeneity or diversity in a community. Education and economic empowerment of women should also be targeted.