Unmet reproductive health needs among women in some West African countries: a systematic review of outcome measures and determinants

Martin Amogre Ayanore, Milena Pavlova and Wim Groot, 2016

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Résumé

Le présent document se concentre sur trois niveaux de besoins non satisfaits en matière de santé génésique (reproductive et sexuelle) : l’utilisation des contraceptifs, les soins obstétricaux et l’utilisation des soins prénatals. Les résultats de cet examen indiquent que les mesures actuellement appliquées aux besoins des femmes en matière de santé génésique pourraient être insuffisantes pour atteindre les meilleurs résultats pour la mère puisqu’elles semblent assez larges. Un plus grand soutien et des recherches pour élaborer et faire avancer des mesures liées au contexte peuvent aider à améliorer la santé maternelle des femmes.

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Globally, more than half a million women aged 15–49 years die annually from preventable pregnancy-related complications [1, 2]. Women in developing countries have a 1 in 26 chance of dying from pregnancy and abortion compared to 1 in 9400 chances in Europe [3]. One of the factors associated with this outcome is the unmet health need for contraception and reproductive health services. Unmet reproductive health needs exist if there is a gap between a perceived need and the current available options to satisfy the need. This paper focuses on three levels of unmet reproductive health needs: contraceptive service use, obstetric care, and antenatal care utilization.

Identifying relevant measures of women’s reproductive health needs is critical to improve women’s chances of service utilization. The study aims to systematically review and analyze the adequacy of outcome measures and determinants applied in previous studies for assessing women reproductive health needs across West Africa.

Results show increasing unmet need for women’s reproductive health needs. Socio-cultural norms and practices resulting in discontinuation of service use, economic constraints, travel distance to access services and low education levels of women were found to be key predictors of service utilization for contraception, antenatal and obstetric care services. Outcome measures were mainly assessed based on service utilization, satisfaction, cost, and quality of services available as core measures across the three levels assessed in this review.

Specificity of outcome measures in reviewed publications

Table 1

Cross tabulations of outcome measures and reproductive health need at three levels in reviewed publications

Category of outcome measures	Reproductive health needs at three levels for married and non-married women
	Antenatal care	Contraceptive use	Obstetric care
Clinical outcomes	1. Number of Antenatal care during pregnancy	1. Service constraints	Critical obstetric danger signs knowledge
	2. Place of delivery(Home/facility)	2. Demand satisfied	Preparations by women prior to delivery and facility type
	3. Supervised or Non-Supervised delivery	3. Provider Intimidation	3. Facility quality and resources
	4. Use of Traditional birth attendant for delivery	4. limited contraceptive choice	4. Obstetric maternal outcomes
	5. Mother survival	5. Nurses withholding information	5. Obstetric utilization/complication
	Newborn survival	6. Method choices at facilities	6. Quality of obstetric care
	Level of utilization and quality of service	7. Unintended pregnancies
	8. Language of service provision	8. Unmet contraceptive seeking demand
Economic and geographical outcomes	1. Service utilization for postnatal services	1. Unmet need for contraception	1. Economic access to obstetric care
	2. Economic access to service	2. Service constraints	2. Risk of intrapartum and antepartum still birth
	3. Out-of pockets payments	3. Economic access	3. Place of delivery
		4. Use of modern contraceptives	4. Delay in seeking care
		5. Community level/ecological zone	5. Delay in reaching a health facility
			6. Delay in been provided with appropriate care
Patient-reported outcomes	1. Service constraints	1. Current use	Demand satisfied
	2. Demand satisfied	2. Ever use	Quality of service delivery
	3. Quality of service delivery	3. Never use	Awareness of danger signs
	4. Decision making choices for maternal care	4. Intention for future use	Emergency planning steps awareness by women
	5. Safe delivery	5. Unmet need for contraception	Reasons for seeking abortion and post abortion services
		6. Contraceptive prevalence rates	Unsafe abortions
		7. Proportion of demand satisfied
		8. Knowledge of contraception use
		9. Current and Ever use of FP
		10. Demand satisfied
		11. Quality of service delivery

The extent of unmet need outcomes reviewed in publications

Table 2 summarizes three critical outcome measures reported in the publications reviewed. These outcome measures were mostly assessed and reflect only contraceptive use across clinical, economic and patient levels. Antenatal and obstetric care were not extensively highlighted in the reviewed publications and thus, not included here. As evidenced in Table 2, unmet need for contraceptive use remains high across all countries. Ghana has the highest level of this type of unmet need across West Africa and Nigeria has the lowest rate. Contraceptive prevalence rates are highest in Ghana and lowest in Benin. Modern contraceptive prevalence rate reflects current acceptance and use of modern methods of contraceptive for all age groups. Hence, low rates depict low use and acceptance to modern contraceptive use may translate to low use in the future. Adolescent’s birth rates, though declining, still remain high and stagnant among most adolescent girls in West Africa (see Table 2). Mali and Benin indicated an increase over a five year period (2001–2006). Two countries, Ghana and Burkina Faso showed a remarkably reduction in the rates for various years, however large disparities still exist across all social and economic groups.

Specificity on determinants in reviewed publications

Table 3

Cross tabulations of determinants and reproductive health need at three levels in reviewed publications

Category of determinants	Reproductive health needs at three levels for married and non-married women
	Antenatal care	Contraceptive use	Obstetric care
Socio-cultural factors	1. Ethnicity and residence of women	1. Women age and parity	1. Cultural acceptability
	2. Cultural viewpoints and beliefs	2. Number of surviving children	2. Social stigma
	3. Family unions of women	3. Spousal communication	3. Socio-demographic factors
	4. Increasing Parity needs	4. Husband refusal to use, socio
	5. Husband/parental influence	5. cultural and religious beliefs,
	6. Empowered decision making beliefs	6. desire for large family size
	7. Religion (ATR)	7. Desire for their husband attention, love and favor
	8. Social factors	8. Marriage status of women
Institutional/clinical factors	1. Access by distance	1. Poor health infrastructure	1. Poor health service infrastructure
	2. Economic cost	2. Unfriendly relational attitude of health providers	2. Lack of skilled personnel for obstetric services
	3. Geographic inaccessibility	3. side effects of use	3. Place of delivery
	4. Poor health infrastructure	4. Method choices available for women	4. Physician inadequate to deliver services
	5. Unfriendly attitude of health providers	5. Ineffective leadership in managing and monitoring the demand	5. Optimal organization of obstetric services
	6. Unavailability of health staff at facility		6. Poor and inefficient counselling
	7. Poorly equipped health infrastructure
	8. Type of facility (private/public/Hop/clinics
Economic factors	1. Socio-economic status	1. Socioeconomic status of woman	1. Cost effectiveness in accessing services
	2. Household wealth	2. Economic Access for contraceptives	2. Travel cost and distance
	3. Cost of accessing delivery services	3. Residence(rural/urban	3. Catastrophic expenditures
	4. Women value in society
Knowledge and risk factors	1. Educational Status of women	1. Previous experience	1. Restrictive abortion laws
	2. Knowledge of danger signs	2. Fear of side effects	2. Poor knowledge concerning
	3. High risk patient risk	3. Educational status of woman	3. Lifesaving skills (LSS) for health staff
	4. Risk of associated with utilization of services

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