Obstacles to Prenatal Care and Safe Deliveries for the Urban Poor

The Ouagadougou Health and Demographic Surveillance System (Ouaga-HDSS), established in 2008, collects data in five neighborhoods located in the northern outskirts of the OUAGA capital of Burkina Faso. Data on demographic events (births, deaths, unions, migration events) are collected every 10 months. Three spontaneous neighborhoods (45 700 residents) and two FOCUS zoned areas (40 700 residents) were selected to study the problems of the urban poor, and to test innovative programs Policy Solutions Based on Evidence that aim to promote the well-being of these populations. 2015 - Number 3

Obstacles to prenatal care and safe deliveries for the urban poor

Limited access to health care during pregnancy and Figure 1. ANC visits by pregnant women in Nairobi and Ouagadougou HDSS, 2009‐2011 delivery is a key driver of the high rates of maternal morbidity and mortality in sub‐Saharan Africa. An‐ tenatal care (ANC) helps detect possible obstetric complications, where assistance by skilled birth at‐ tendance at delivery is among the most important factors of maternal survival. Yet the urban poor in Africa are likely to encounter a number of obstacles to accessing maternal health services.

Key Findings

 Nearly all pregnant women in Ouagadougou (95%) deliver at health facilities but only 22% Comparing Nairobi and have all four recommended visits. Ouagadougou  Women in Nairobi are twice as likely to have all The individual characteristics related to maternal four recommended ANC visits but much less health service utilization are well‐known: better likely to deliver in a hospital (80%) educated, better off women and women closer  In Nairobi, the existence of small private to services are generally more likely to use them. facilities, close to the slums and affordable, may Much less is known on the policy and service help women complete all four visits, but they delivery context that promotes maternal service seem to be offering services of poor quality. utilization. To start filling this gap, we compared  In Burkina Faso, legislation forbidding village maternal health service utilization in two Health birth attendants in urban areas is well enforced and Demographic Surveillance system (HDSS) and drives women in Ouagadougou to deliver in located in the informal areas of Nairobi and health facilities for lack of alternatives. Ouagadougou.

Ouaga Focus is published by the Institut Supérieur des Sciences de la Population ‐ ISSP University of Ouagadougou ‐ BP 7118 ‐ 03 ‐ Ouagadougou ‐ Burkina Faso Tel : +226 50 30 25 58/59 www.issp.bf/opo

2 — Ouaga Focus, 2015, Number 3 — Obstacles to prenatal care and safe deliveries for the urban poor

Better antenatal care in Nairobi Figure 2. Place of delivery for women in Nairobi and Ouaga‐ dougou HDSS, 2009‐2011 In both HDSS areas, nearly all pregnant women had at least one ANC visit, but women in Nairobi were twice as likely to complete the recom‐ mended four visits (Figure 1). In Ouagadougou, there were no differences among groups of women for having at least one ANC visit, in con‐ trast to Nairobi, where disadvantaged women were more likely to have had no ANC.

Better skilled delivery in Ouagadougou Despite the fact that more pregnant women in Nairobi complete four ANC visits, skilled attendance at delivery is lower in the slums of Nairobi compared to Ouagadougou (Figure 2). Nearly all

women (95%) in Ouagadougou delivered in a health facility, compared to only 80% in Nairobi. The lower proportion of women in Nairobi who have facility deliveries may explain in part the higher relative maternal mortality rates previously found in Nairobi. © ISSP/OPO Programmatic Implications Regulations promoting maternal health service utilization Context, especially local legislation and service delivery practices, appears to have a strong influ‐ This difference in ANC visits between the two sites may ence on both ANC visits and facility delivery, and be due to the fact that health providers in Ouagadougou this should be accounted for in any local program check that women have at least ANC visit when they design and implementation. The actual enforce‐ come to deliver in a health facility; this practice may en‐ ment of regulations seems to be a key driver of courage all women to have at least one ANC but not to the positive outcomes in Ouagadougou. complete all four visits. Moreover, in Nairobi, the exis‐ The private sector can also increase the capacity tence of small private facilities, close to the slums and of the health system to provide complete care to affordable, may help women complete all four visits, but all pregnant women, if the services offered are they seem to be offering services of poor quality. Better affordable; however, their quality needs to be coverage in assisted delivery in Ouagadougou may be monitored. Voucher programs (one is currently due to a well‐enforced legislation forbidding village birth being tested in Nairobi) can help subsidize private attendants in urban areas : women in Ouagadougou to health facilities while controlling the quality of deliver in health facilities for lack of alternatives. the service they offer. Further information Ouagadougou  Rossier Clémentine, Kanyiva Muindi, Abdramane Soura, Blessing Mberu, Bruno Lankoande, Caroline Kabiru, Health and Roch Millogo (2014) « Maternal Health Care Utilization in the Slums of Nairobi and Ouagadougou: Evidence form HDSSs”, Global Health Action, 7: 24351 Demographic  Results based on a research funded by Wellcome Trust Surveillance  Questions or comments : [email protected] System  Other Ouaga Focus : http://www.issp.bf/opo/English/Publications/OuagaFocus.html  Printed with the support of l, Ouaga Focus are edited with the participation of