The sixth Demographic and Health Survey in Mali reports an increase in four or more ANC visits over the past two decades: from 43% of women in 2001 to 68% in 2018. Furthermore, considerable progress has been made for the percentage of live birth deliveries in a health facility, increasing from 38–67% in the same time period . Despite these improvements in healthcare utilization, maternal mortality remains a major cause of death among Malian women .
The district of Sélingué is about 1.5 hours away from the capitol of Bamako, and there is overall moderate geographic access to healthcare facilities. However, even within Sélingué, there is variation that has real impacts on usage of maternal healthcare and facilities.
Access to care and the underutilization of healthcare are key factors that impact maternal mortality . Yet in the health district of Sélingué, close to the national capital, with moderate geographic access to health services, there are clear disparities within the district. As noted in existing studies, the unequal distribution of healthcare facilities according his geographical accessibility in West African regions is rarely discussed [23–26]. The internal disparities identified in this paper provide insight into why some women still experience poor maternal healthcare utilization and access, despite living in moderate geographic access regions of Mali. As depicted in Figs. 1, 2 and 3, the concentration curve demonstrates a lack of equity of access to delivery by healthcare facility and for women receiving four ANC visits. Gaps in education and distance from the facility are well documented as factors affecting ANC utilization and birth in healthcare facilities [7, 13, 27]. However, the provided data highlights how geographic access varies within this moderate access district, and how that affects maternal health equity and utilization access in Sélingué.
Women still face substantial barriers in the health district of Sélingué, despite this region having many health facilities. The distribution of these health facilities is not conducive to the equitable access of healthcare by all women in the district. A sizeable portion are still not delivering in a health facility or receiving ANC, and this is based on their distance from the facility, among other social factors.
Completion of a woman’s first ANC visit in the earliest stages of her pregnancy (the first four months) is significantly associated with the completion of four or more ANC visits. Additionally, older pregnant women are more likely to complete four ANC visits. In addition to this timing, distance represents further disparity. The chance for a pregnant woman to have four or more prenatal visits decreases beyond a distance of 15 km between her home and a first-level health facility. As the distance between the health facility and a woman's village of residence decreased, her likelihood of attending four ANC visits increased.
The importance of evenly distributed health care facilities within moderate geographic access areas should not be neglected simply because they already have better access than low geographic access regions. The data tables demonstrate that if women living in villages between six to 15 kilometers from a community health facility, they are 50% less likely to achieve four or more ANC visits during pregnancy and 80% less likely to deliver in a health facility [Table 2, Table 3]. Distributing health facilities more equally, or other efforts to bring care closer to women, can improve ANC services utilization in these more moderate geographic access areas. The findings reinforce that addressing utilization barriers is necessary in order to comply with the WHO recommendations for achievement of four or more ANC visits, facilitating childbirth in a health facility, and promoting equitable distribution of maternal health care and services .
In addition to even facility distribution, attention should be given to gender equality and women’s unequal access to education. A study completed by Ahmed et al., describes a concept similar to the 3-delays model but called the 3-Es . This study recognizes a woman’s economic, education, and empowerment status as key indicators to maternal healthcare utilization . Similar to the 3-delays (delays in seeking care, delays in arriving at the health facility, and delays to being provided care), there are inequities in the 3-Es. As supported in our data, women who are experiencing inequities in our education variable have lower healthcare service utilization (Table 3). Our data points to the larger socio-structural disadvantages that women face, and must be addressed country-wide, not only in Sélingué, to see long-term progress in women’s maternal health. Efforts and interventions should be centered around gender equality by virtue of girl’s education to improve women’s overall maternal health as well as increase their utilization of health services.
Attention must continue to be placed in moderate geographic access areas such as the health district of Sélingué. Interventions should focus on addressing the determinants of the usage of equitable maternal healthcare, such as the 3-Es and distance. Addressing these inequities will position Mali to be capable of achieving the third Sustainable Development Goal: to ensure healthy lives and promote wellbeing for all, at all ages.
Our results align with previous studies that show higher educational attainment as significant in influencing birth in a health facility [27, 30]. Additionally, distance beyond five km of a health facility was significantly associated with a decrease in health facility utilization. There are some studies that contrast with our findings in their analysis of inequalities in the use of maternal care. In a range of low- and middle-income countries (LMICs), with particular attention to the low geographic access, moderate and high geographic access areas disparities, the association between place of residence and receipt of early ANC was not consistent . Some LMICs, like India, did not show a significant difference in ANC when comparing high geographic access areas and low geographic access areas with respect to their distance from health facility. However, it stands undisputed that antenatal care, childbirth, and postpartum care provided by a health facility are key factors in preventing maternal and neonatal mortality .
Study Strengths and Weaknesses
This research was conducted as a cross-sectional study with a retrospective survey. In this type of study design, there is a possibility for recall biases in our survey response subjects, which may affect our results of care-seeking behaviors. Additionally, a selection bias may also be at play since women who died during pregnancy, labor, or delivery before the survey was conducted were not included in the analysis.
Suggestions for Further Research
More research and in-depth assessments are needed to better address the interactions of these social determinants, and their impact on improving maternal healthcare utilization.
As noted in similar studies and systematic reviews, some countries of similar income levels do not see as stark disparities as Sélingué, Mali . If their inferences are true, possible points of additional research can be to articulate what allows for the mediation of these disparities. Particularly, what interventions, programs, or data is necessary to ensure a more equitable distribution of healthcare facilities and services in moderate geographic access-classified areas. Other questions surround the impact of community-based transport systems and the construction of more referral care facilities that indirectly or directly impact the use of maternal health care.
During our proposal writing, we carried out an exchange visit to assess an obstetric emergency transportation system from villages to community health center delivered in the Diema health district. Data analysis showed that the obstetric emergency transportation system from villages to community health center can improve the use of delivery at health facilities.