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Introduction: Maternal mortality is one of the main causes of death for women of childbearing age in Mali, and improving this outcome is slow, even in regions with relatively good geographic access to care. Disparities in maternal health services utilization can constitute a major obstacle in the reduction of maternal mortality in Mali and indicates a lack of equity in the Malian health system. Literature on maternal health inequity has explored structural and individual factors influencing outcomes but has not examined inequities in health facility distribution within districts with moderate geographic access. The purpose of this article is to examine disparities in education and geographic distance and how they affect utilization of maternal care within the Sélingué health district, a district with moderate geographic access to care, near Bamako, Mali. Methods: We conducted a cross sectional survey with cluster sampling in the Sélingué health district. Maternal health services characteristics and indicators were described. Association between dependent and independent variables was verified using Kendall’s tau-b correlation, Chi square, logistic regression with odds ratio and 95% confidence interval. Gini index and concentration curve were used to measure inequity. Results: Most respondents were 20 to 24 years old. Over 31% of our sample had some education, 65% completed at least four ANC visits, and 60.8% delivered at a health facility. Despite this evidence of healthcare access in Sélingué, disparities within the health district contribute to inadequate utilization among approximately 40% of the women in our sample. The concentration index demonstrated the impact of inequity in geographic access, comparing women residing near and far from the referral care facility. Conclusion: Maternal health services underutilization, within a district with moderate geographic access, indicates that deliberate attention should be paid to addressing geographic access even in such a district.
The study was conducted in the health district of Sélingué, located 145 km southwest of Bamako. A health district is a geographic zone defined by the Malian government to provide public and private integrated healthcare as well as supported services (laboratories, logistics, etc.). The study district is made up of 60 villages with a total of 91,425 inhabitants, and it is divided into seven sub-districts. Each sub-district has a community health center where women receive their antenatal and maternal care. The one referral care facility, the district hospital, is staffed by one or more physicians, while the sub-district health centers are run by a center technical director, usually a nurse, with the exceptions of Siékorolé and Diarani, where the health center is run by a physician. We conducted a cross-sectional survey with cluster sampling proportional to village population size at two levels for a total of 30 clusters. The first stage was the randomized selection of the seven sub-districts, then the random selection of the villages within the chosen sub-districts. At the last stage, we conducted random sampling to select the families in the village that included at least one eligible woman. Women were eligible to participate in the study if: The number of clusters per village depended on the population size. Thus, villages with a relatively high population had more clusters than villages with a lower population. In total, we selected 960 households, or 33 households per cluster, with at least one eligible woman in each household. The protocol was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health of Baltimore, and the Faculty of Medicine and Pharmacy at the University of Sciences, Techniques and Technologies of Bamako. Physical risks to study participants were negligible. Overall, this was a minimal risk study that did not involve any administration of medications or other substances, medical or surgical procedures, and no biological samples were collected. All investigators were trained in data collection techniques, including a module on the protection of human subjects, informed consent, and maintaining confidentiality. A written consent form was signed and dated by interviewees and the investigators. We conducted face-to-face interviews using a questionnaire. All investigators were trained in data collection techniques including a module on the protection of human subjects, informed consent and maintaining confidentiality. We collected data on the age of the women, the level of instruction, the parity, the distance between the village and the health facility, the number of ANC visits and the age of pregnancy at the first ANC visit. Data was collected with Samsung Galaxy tablets, sent to an online server (Magpi), and extracted using Microsoft Excel. We established a standardized description of the characteristics and indicators of maternal health service utilization. After quality control and correction, excel spreadsheets were merged into a single SPSS database. According to the Mali 2018 National Health Information System, 57% of the population is within 5 km of a health facility (Ministère de la Santé et de l’Hygiène Publique, 2018), however, we classified geographic access areas in the following three categories: We performed an analysis between dependent and independent variables using simple and multiple logistic regression Chi-square tests to measure the determinants of service utilization. The gross and adjusted odd ratios were calculated with a 95% confidence interval and a p value of 0.05% for a significant difference. We verified the association between dependent variables and independent variables that have more than two modalities by using Kendall’s tau-b correlation. Variables that had a significant association during bivariate analysis were put into the model. To measure equity in geographic access, we calculated the Gini index and constructed a concentration curve. The concentration curve presents a visual graph of inequity in the use of health care and compares the level of inequity over distance. The Gini index is a quantitative measure of inequity in the use of healthcare, defined as “twice the area between the concentration curve and the equity line, to measure the degree of inequity systematically associated with distance” (Wagstaff et al., 1991). These two methods are standard measures to estimate inequity related to a variable on various health indicators (Babinard & Roberts, 2006). We interpreted the inequity measured through the concentration curve and the concentration index as horizontal inequity, since all women were assumed to have the same maternal health needs, e.g. need for delivery in a referral health care facility, regardless of baseline characteristics (Zere et al., 2010). While the concentration curve is a useful tool for graphically representing inequity, it does not quantify the magnitude of the inequity. Economic status was measured using the wealth index model taken from the Bangladesh Demographic and Health Survey (Rutstein & Johnson, 2004). Geographic accessibility was estimated using the index of distance between a women’s village of residence and local health facilities by using the concentration curve and the concentration index (distance index from place of residence to health facility). This index places women’s villages of residence individually on a continuous scale of relative distance. Five quintiles of distance were used to categorize distance of the women to their health facility and to measure its influence on their maternal health indicators. Both principal components and factor analysis were carried out (Hossain, 2010). The value of the concentration index is between − 1 and + 1. A value of 0 indicates that the use of health services is equitably distributed among socio-economic groups. The value of the distance index below zero indicates that women in remote places of residence use more health facilities than women in areas further from health facilities. A value above zero implies that women residing furthest from a facility use health services less than women who reside closer (Wagstaff et al., 1991).
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