Inequalities in reproductive health care use in five West-African countries: A decomposition analysis of the wealth-based gaps

BACKGROUND: Family planning and maternal care services have become increasingly available in West Africa but the level of non-use remains high. This unfavorable outcome may be partly due to the unaffordability of reproductive health care services. METHODS: Using the Demographic Health Survey data from Burkina Faso, Niger, Nigeria, Ghana, and Senegal, we perform a decomposition analysis to quantify the contribution of socio-demographic characteristics to disparities in exposure to mass media information on family planning, use of modern contraceptives, adequate antenatal care visits, facility-based childbirth and C-section between low-wealth and high-wealth women. RESULTS: Our study shows that differences in maternal characteristics between the wealth groups explain at least 40% of the gap in exposure to mass media family planning information, 30% in modern contraceptive use, 24% of adequate antenatal care visits, 47% of the difference in facility-based childbirths, and 62% in C-section. Lack of information on pregnancy complications, living in rural residence, religion, lack of autonomy in health facility seeking decision, need to pay, and distance explains the disparity in reproductive health care use across all countries. In countries with complete fee exemption policies for specific groups in the population, Ghana, Niger, and Senegal, the inequality gaps between wealth groups in having an adequate number of antenatal care visits and facility-based childbirth are smaller than in countries with partial or no exemption policies. But this is not the case for C-section. CONCLUSIONS: There is evidence that current policies addressing the cost of maternal care services may increase the wealth-based inequality in maternal care use if socio-demographic differences are not addressed. Public health interventions are needed to target socio-demographic disparities and health facility seeking problems that disadvantage women in poor households.