Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo – A Case study of Lubumbashi City

Antenatal consultations (ANC), skilled attendance at birth, and postnatal care (PNC), which form the objective of this study on maternal and neonatal healthcare services, are among the pillars of safer motherhood. Their efficacy is proven in the prevention of obstetrical risks [1, 2] but their use is still lacking. Large gaps still exist between the rich and poor countries on the utilization of these services where, for example, 80% of pregnant women attended ANC at least once in 2007. Less than half followed the recommended number of consultations [3]. Gaps also exist in the provision of antenatal healthcare in the country [4].

In the Democratic Republic of Congo (DRC), 85% of pregnant women attended ANC at least once in 2007. However, this coverage was different between urban areas and rural areas; 92.0% and 80.9% respectively, and only 78.0% in the province of Katanga, which is among the lowest in the country [5].

Whereas the proportion of assisted childbirth is increasing significantly worldwide [3], there is still room for improvement in low-income countries [5]. For example, while in 2007, 80% of deliveries throughout the world took place in the presence of qualified healthcare personnel; this coverage only reached 60% in poor countries [3]. In DRC, this was only 74% and in the province of Katanga 70%; with wide gaps between urban and rural environments. [5].

The reduction of infant mortality in the under-fives is in part linked to that of perinatal mortality. Therefore, the former cannot be expected to reduce without improving the women’s access to perinatal health services [1, 6].

Just to take an example of neonatal mortality, Darmstadt et al. [1] showed that when community-based antenatal healthcare at health facilities is used in ideal conditions and in a population with a ANC coverage of 99%, and when this healthcare is coupled with skilled assistance at delivery and postnatal care covering 90% of the population, it is possible to reduce neonatal mortality by over 70%. They also show that this perinatal healthcare is more beneficial and profitable when provided as a package rather than in the form of isolated interventions.

In Lubumbashi, the use of such services, recognised to be an indirect indicator of the perinatal mortality rate, however, remains unknown, which makes it difficult to assess the progress made in pursuit of MDG4-5. Moreover, since the use rate of these services is unknown, the factors explaining this rate are not known either. It is indeed necessary to determine the use rate of mother and child healthcare services in this environment, so that their impact on the maternal-foetal and neonatal prognosis can eventually be evaluated.

The present study was therefore undertaken in order to determine the factors that influence the use of mother and child healthcare services in Lubumbashi, Democratic Republic of the Congo.

In Lubumbashi, the majority of pregnant women go for antenatal consultations and give birth in healthcare facilities, but still make very little use of postnatal consultations.

In fact, though women do go for antenatal consultations, most of those who used this service were not properly aware of its advantages. The women considered that such services had more advantages for the foetus than for themselves (Table 2). This lack of knowledge among women with respect to the twofold advantages of this service (maternal, as well as foetal and neonatal), reflects a deficiency in information due to an absence of continuum in these services between healthcare facilities and the community [14–19]. These findings corroborate well with the observations of Anya et al. [20] who noted in Gambia that the source of information on antenatal consultations was mainly women, close acquaintances (mother-in-law and friends), and in a very small proportion, health personnel. From the above, it follows that the extent of utilising NPC and health treatment offered during these consultations, is an indication of the information available to women [18–21]. The better informed women are, the more demanding they will be regarding the nature and quality of the healthcare that they need. They will thus make favourable decisions in terms of the start and frequency of their antenatal visits.

Concerning the start of ANC, it was noted that most women started late with these visits (in the second trimester of pregnancy), and that less than half completed the recommended number of visits throughout their pregnancy [11, 22]. Moreover, it also appeared from our findings that the women did not follow a specific schedule for their ANCs. Most of them started their antenatal visits only when they had the financial means or time, or felt unwell (Table 3); only 20% of the women started with antenatal visits according to a planned schedule. This behaviour, which was also observed in several other African regions [4], can be attributed to the lack of adequate information on the content and schedule of antenatal visits [21], and constitutes a serious barrier to the utilisation of all the interventions recommended for efficient pregnancy care.

It also appears from the study that HIV and planning for delivery were not frequently discussed between health personnel and pregnant women during antenatal visits. The proportions of women who had access to these services were low, and were similar to those observed in various other African countries where health systems appear unstable. In such context, health personnel are inclined to focus on more lucrative activities than communicating with pregnant women [23]. Therefore, the small amount of communication between health personnel and pregnant women regarding their delivery plan can be explained by the low percentage of women who complete their series of antenatal visits, given that this issue is normally discussed on the last visit [24–26]. The scarcity of information that could raise awareness of HIV is in turn due to a very low coverage of PMTCT activities in healthcare facilities (less than 15% in Katanga) [4, 5].

Besides the deficient raising of awareness and delivery planning, women did not undergo all of the recommended physical examinations and laboratory tests during antenatal visits. The proportion of those who underwent examinations for oedema in the lower members was low compared to other towns in Africa [4, 16]. This attitude, which is a barrier to detecting potential risk factors, deprives women of the chance to benefit from adequate healthcare when needed.

The proportions of women who had used sulfadoxine-pyrmethamine (SP), iron, folic acid, or insecticide-treated mosquito nets (ITN), and those who were vaccinated against tetanus or had been tested for HIV, were low and of a great cause for concern, since the antenatal visits had not presented an opportunity to provide them with appropriate healthcare. These were, on the contrary, missed opportunities during which the women had limited contact with the health facility and personnel, without ever benefiting from health interventions that nevertheless were proven to be effective in preventing and treating most of the problems (such as anaemia, malaria, HIV infection and tetanus) encountered in pregnant women in poor, tropical areas such as the DRC [4]. The main reasons for these missed opportunities are on one hand, the lack of availability of such treatments, and on the other hand, the women’s lack of financial means.

Certain health treatments such as SP or tetanus vaccination should be given to women free and administered under observation. In the case of iron, folic acid and ITN, which they must continue to use at home, healthcare services must be organised in such a way that they can be provided to women free, or at affordable prices so that they do not need to make the extra effort of procuring them elsewhere. However, from lack of such inputs in healthcare facilities, health personnel are often obliged to issue prescriptions to pregnant women, without knowing whether they will follow them. Very few women follow such prescriptions if especially they consider that their state of health does not require them to take the medicines, or they do not have the means to buy them. In India, for instance, Lim et al. noted an increase in the use of health treatments in areas where they were freely available, as opposed to areas where pregnant women or their families had to pay for them [23]. In Lubumbashi, subjecting pregnant women to additional costs (besides that of the consultation sheet) before they access to tetanus vaccination for instance, contributed enormously to limiting their access to such treatments.

We also observed in the course of this study that most women gave birth at healthcare facilities. Regarding home births, women mentioned lack of financial means as the main reason for not going to a healthcare facility, but a considerable proportion of the women considered it less important to give birth in a healthcare facility, given the experience they had already gained from previous deliveries. This behaviour, which is not beneficial to women, goes hand in hand with a misconception of the risks of childbirth, and can be attributed to insufficient or poor communication between healthcare facilities and the community in general, and women in particular [24]. Mobilising the community and creating interaction between healthcare facilities and the community are indispensable and a matter of urgency, in order to reinforce the information that is given to women, and improve their perception of the risks involved in pregnancy and childbirth.

In contrast to the observations made by Chenge et al. [7], the Caesarean-section rate in our study was 4.5%. This rate is nearly three times higher than the one reported by the aforementioned author, but twice lower than in other African countries [4]. The difference in the two rates that were calculated in the same city is due to the calculation methods. Chenge et al. estimated this rate according to the number of expected births in Lubumbashi, whereas the rate in the present study was calculated directly among women who participated in the study. However, seen as an indicator for assessing the level of maternal mortality, the Caesarean-section rate remains low and indicates an under-utilisation of this procedure in Lubumbashi [27].

Postnatal visits in turn are rarely used by women in Lubumbashi, even when one allows for a 42-day lapse after birth [4]. Postnatal visits were more frequent at 42 days than at seven days, since the 42^nd day coincides with the start of preschool visits [28]. Superstition to the fact that newborns will be exposed to demonic influences and witchcraft if taken outside the house in the first month has been mentioned in other areas as a reason for delaying the first visit. Visits starting at 42 days therefore correspond to the moment when mothers consider that their child is no longer in such danger [28]. These beliefs, combined with a lack of motivation to go for postnatal visits, also indicate deficiency in the information given to women.

Regarding factors that determine the utilisation of maternal healthcare services, we observed that primiparity, grand multiparity, and unwanted pregnancies issues associated with the non-utilisation of antenatal visits. Reasons suggested for the non-utilisation of postnatal visits were the lack of antenatal visits, the absence of complications during birth, and unwanted pregnancies.

In fact, we noticed that women who were pregnant for the first time, and those who had been pregnant many times, were at greater risk of not using ANC than those who had been pregnant a few times. These observations correspond with findings from other studies [29–43]. The tendency for first-time pregnant women to make less use of ANC could be explained, on the one hand, by the lack of information on pregnancy management (e.g. presence of maternity facilities that are integrated in the community and destined for women of childbearing age). On the other hand, women who had been pregnant many times were less inclined to go for antenatal visits due to their misconception of the risks of pregnancy, because of experience gained from previous pregnancies and births [44].

The utilisation of antenatal consultation did not affect the fact of giving birth at a healthcare facility or not. However, it did influence the likelihood of going for postnatal visits. This influence is due to the climate of trust generated by the friendly relationships that are gradually built up between women and health staff, and which becomes a motivational factor for the women to go for postnatal visits [3]. Complications arising during the delivery have an effect on the utilisation of postnatal consultations, due to the women’s perception that such complications present a threat to maternal and neonatal survival. In this context, postnatal visits become a necessity in order to improve the prognosis. This observation suggests therefore that the message given by health personnel encouraging women to make use of postnatal consultations is selective. Health personnel tend to insist more on postnatal visits for women who had complications during the delivery, than for those who gave birth without any problems.

Birth planning was also associated with the utilisation of mother-child healthcare. In the present study, women who planned their pregnancy, whether alone or with their partners,were more inclined to make use of pre- and postnatal consultations than those whose pregnancy was unplanned. This association shows the need to have and reinforce family-planning services. From a psychological viewpoint, a planned pregnancy is usually better accepted by the women, which motivates her to adopt a favourablebehaviour pattern, for instance making use of healthcare services at recommended times or when there is a problem, in order to benefit from treatment that is appropriate for the situation [4, 33].

This study, which was carried out in an essentially urban environment, has certain limitations that must be pointed out.

Firstly, we did not investigate the role of insufficient financial means, which is generally recognised as a barrier to the utilisation of healthcare services [29]. The fact that the impact of this factor on the utilisation of mother-child healthcare is not mentioned, does not mean that it is not a determining factor for these services. In fact, women frequently mentioned it as being an obstacle to going for antenatal visits as well as giving birth at a health facility. The absence of this element among the determining factors is due to a high rate of respondents who did not answer questions that could have been used for calculating the poverty index of households. This attitude was explained by the fear of being burgled or threatened, according to the women.

Secondly, we considered that distance, which was not included in the determining factors for this study, was not an obstacle to the utilisation of services, given that the city of Lubumbashi is divided into healthcare zones that are mainly urban, where almost all health areas are operational and easily accessible. Nevertheless, this appreciation does not exclude considerations related to preference. A woman may prefer a healthcare facility that is further from her home, rather than one that is closer by, due to factors like cleanliness, presence of medicines, or the presence of friendly staff.

Thirdly, aspects such as community participation and balanced social relationships between men and women could also influence the use of mother-child healthcare services.

In Lubumbashi as in the rest of the DRC, activities relating to healthcare services for mothers, newborns and infants are generally delivered as clinical or outreach services; there are no family- or community-based services; nor are there any cooperation mechanisms between the healthcare system and the community. In this context, the community plays a passive role in the service offer, which is limited to paying fees for services received. The fact of not associating with the healthcare service offered could account for the lack of information observed in this study, and explain why the quality of these services does not improve, when the community has no mechanism for holding the healthcare system to account [7].

Moreover, social imbalance in favour of men could also explain the rate of healthcare use. In Lubumbashi for instance, only one woman for every three men has a paid job [5]. This ratio means that most women are financially dependent on men. The lack of autonomy could also be an element that determines the use of mother and child healthcare services, since the decision to make use of such a service is often left to the man. Therefore, if the man does not participate in mother-child healthcare activities, it is natural that his ignorance, combined with the decision-making power of which he holds the monopoly in the household, could have a negative impact on the use of services.

These considerations imply that information to women may well be improved, but that if the participation of the community and the autonomy of women are not reinforced, then neither could the use and quality of mother-child healthcare services be improved.

Such biases could for instance have influenced the gestational age at the first antenatal visit, for in Lubumbashi, this age is mainly determined according to the date of the last menstrual period, which some women may have forgotten. Moreover, since women’s statements were confirmed by the information recorded in ANC records and files, we do not exclude the possibility that the recording of certain data may have been forgotten by the staff of this service, even if in most cases, the information given by the women correlated with that found in the documents.

Fourthly, we do not exclude the possibility that these findings may be limited by memory bias which is inherent to surveys based on questionnaires, given the fairly large number of months between delivery and the date on which the women responded to the questions.

In Lubumbashi, a significant proportion of women continue not to make use of healthcare services during pregnancy, as well as during and after childbirth. Women giving birth for the first time, those who have already given birth many times, and women with an unwanted pregnancy, made less use of ANC. Moreover, women who had not gone for ANC rarely came back for postnatal consultations, even if they had given birth at a healthcare facility. Similarly, those who gave birth without complications, less frequently made use of postnatal consultations. As with ANCs, women with unwanted pregnancies rarely went for postnatal visits.

In addition to measures aimed at reinforcing women’s autonomy, efforts are also needed to reinforce and improve the information given to women of childbearing age, as well as communication between the healthcare system and the community, and participation from the community, since this will contribute to raising awareness of safe motherhood and the use of such services, including family planning.

ANML and FMK carried out the study and participated in the statistical analysis and procedures. MWD, PD coordinated and participated in the design of the study, statistical analysis and the drafting of the manuscript. All the authors read and approved the final version.