The association between antenatal care utilization adequacy and urban versus rural locality in North and South Kivu, Democratic Republic of the Congo Open Access

Armas, Jean Marie (2015)

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Background: Maternal and newborn mortality in the Democratic Republic of the Congo (DRC) are among the highest in the world. Antenatal care (ANC) is a proven and cost-effective strategy for reducing maternal and newborn mortality. Although 88% of women in the DRC received at least one ANC visit, only 48% of women received the World Health Organization's recommendation of four or more visits. The purpose of this analysis is to assess how urban versus rural place of residence impacts antenatal care utilization adequacy (4-visit model) in two provinces of eastern Congo.

Methods: Using data from the 2010 Multiple Indicator Cluster Survey for the DRC, we examined the association between adequate antenatal care utilization and urban versus rural locality among women of reproductive age (15-49 years old) living in the North and South Kivu provinces of eastern Congo and who reported attending at least 1 ANC visit during their last pregnancy (n=850). We estimated crude and adjusted odds ratios as well as 95% confidence intervals using logistic regression procedures while accounting for the survey design.

Results: Overall, 63.9% of women surveyed attended 1 to 3 visits while only 36.1% of women reported attending 4 or more visits. During unadjusted analysis, we found a statistically significant association between locality and adequate ANC utilization (OR=2.64, 95%CI=1.62-4.29). After adjusting for education and province in the final model, the association remained significant (aOR=2.34, 95% CI=1.43-3.82). The odds of a woman living in an urban area attending 4 or more visits is 2.34 times larger than the odds for a women living in a rural area. In the final model, province was also found to be a significant predictor. Women in North Kivu province were more likely than women in South Kivu province to attend 4 or more visits (aOR=2.47, 95% CI=1.62-3.78).

Conclusion: Although a majority of women attend at least one ANC visit in the Kivus, many do not attend the recommended number of visits. The disparity in adequate ANC utilization between women living in urban areas versus rural areas is suggestive of the need to improve accessibility in rural areas of eastern Congo. Additional findings suggest the need to improve accessibility in the South Kivu province.

Table of Contents

Background. 8

Overview: The Importance of Antenatal Care in Preventing Maternal and Newborn Mortality. 8

Adequacy in Antenatal Care. 9

Adequate Antenatal Care in Resource-Limited Settings. 10

Why Study Health Care Utilization. 11

Individual and Societal Factors Impacting Health Care Services Utilization. 12

Individual Determinants of Health Care Utilization. 12

Predictors of Antenatal Care Utilization. 12

Place of Residence and Utilization of Health Care Services. 13

About The Democratic Republic of the Congo. 13

Maternal and Neonatal Mortality in The DRC. 14

Locality and Utilization of Antenatal Care. 14

Locality and Health Care Outcomes. 15

The Impact of Conflict on Health Care Services in Eastern Congo. 16

The Impact of Conflict on Maternal and Infant Health Outcomes. 16

Study Objective. 17

Methodology. 19

Data Source. 19

Measures. 20

Statistical Analysis. 22

Results. 25

Descriptive Analysis. 25

Bivariate Analysis. 26

Logistic Regression to Determine Crude and Adjusted Odds Ratios. 28

Model Selection. 29

Goodness of Fit and Collinearity. 33

Final Model. 33

Discussion. 34

Study Limitations. 36

Conclusion. 38

Appendix. 40

Appendix A: SAS Code and Tables for Determining Categorization of Variables. 40

Appendix B: Additional Table - Characteristics of Study Population. 59

Appendix C: Final SAS Code. 60

Appendix D: Adjusted Odds Ratios - Interaction Testing. 72

Appendix E: Final Model Selection. 73

Appendix F: MICS 2010 - Questionnaire For Individual Women. 76

References. 149

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