Les facteurs explicatifs de la discontinuité des soins obstétricaux en Afrique: cas du Bénin

Liste des abréviations.

ADDAD : Association pour le Développement et la Diffusion de l'Analyse des Données.

CCS : Centre Communal de Santé.

CHD : Centre Hospitalier Départemental.

CIPD : Conférence Internationale sur la Population et le Développement.

CNHU : Centre National Hospitalier et Universitaire.

CPN : Consultation Prénatale.

CRDI : Centre de Recherche pour le Développement International.

DDSP : Direction Départementale de la Santé Publique.

DEPOLIPO: Déclaration de Politique de Population.

DSRP : Document de Stratégies de Réduction de la Pauvreté.

EDS : Enquête Démographique et de Santé.

EDSB : Enquête Démographique et de Santé du Bénin.

IDH : Indicateur de Développement Humain.

INED : Institut National d'Etudes Démographiques (France)

INSAE : Institut National de la Statistique et de l'Analyse Economique.

OMD : Objectifs du Millénaire pour le Développement.

OMS : Organisation Mondiale de la Santé.

PEV : Programme Elargi de Vaccination

PNUD : Programme des Nations Unies pour le Développement.

PRB : Population Reference Bureau.

REP : Rapport national sur l'Etat de la Population.

RGPH : Recensement Général de la Population et de l'Habitation.

RNDH : Rapport National sur le Développement Humain.

SMI : Santé Maternelle et Infantile.

UNFPA: United Nations Population Fund.

UNICEF: United Nations Children Fund.

UVS : Unité Villageoise de Santé.

VAT : Vaccination Antitétanique.

WHO: World Health Organization.

SUMMARY.

According to Kofi Anan, «the biggest enemy of health in the developing countries is poverty», (WHO, 2002). The World Health Organisation's studies revealed that 99% of the maternal and child mortality occurs in the developing countries, (UNFPA, 2004).

So, it is important to understand why, despite all the political directives and strategies developed by African countries to overcome maternal and child mortality, its level remains so high in the continent.

Since most of the maternal mortality occur during delivery and the near post-partum, it is therefore important that women do carryout the required^2(*) number of antenatal visits and professionally assisted during delivery in order to prevent or quickly detect complications that may occur during delivery.

This study entitled: Studying the explanatory factors of the discontinuity of obstetrical care in Africa: The case study of Benin, helps to contribute to better understand the discontinuity of obstetrical care using an integrated offer-demand approach in order to help the government to better fight against maternal and child mortality. In this study, a woman is said to have a discontinuous obstetrical care as she was not professionally assisted during delivery, after having made at least one antenatal visit. The Demographic and Health Survey (DHS) data sources clearly show that the discontinuity of obstetrical care is still a major problem in Africa with some extremes in countries such as Rwanda, Ivory Coast, Ghana and Niger.

The theorical approach of the study concerns the whole Africa and takes into account the Benin's second DHS database for year 2001. The conceptual chart of the study is an adaptation of the Andersen and Newmann (1972) formalization of the process that leads to the use of health care facilities.

Our main theory is therefore that the process which leads a woman to use health care facilities during pregnancy and delivery depends on one hand, on the predisposing factors such as her own characteristics (age at delivery, education, foregoing caesarean), the characteristics of the household in which she is living (living standard of the household or its poverty level) and the cultural behaviour she shares with the other members of her family or her childhood place of residence and on the other hand, the enabling factors such as the availability, the geographical and financial accessibility of obstetrical care and the quality of the obstetrical services.

Our main theory assumes that the process which leads to the discontinuity of obstetrical care include: firstly, the woman has to be predisposed to search and receive obstetrical care. Secondly, health facilities have to be available, accessible and the maternal and child health professionals have to be highly qualified. Finally, if all these two conditions are satisfied, that woman will have a continuous obstetrical care. But this will not be possible if one of the two conditions is not satisfied. In order to test this theory, we have used the Benin second DHS database for year 2001.

The unit of analysis for this study is the women who have had at least one antenatal visit and the discontinuity concerns the most recent birth in the five years preceding the survey.

The analysis is first descriptive bivariate with the chi-square statistic, and then multivariate descriptive with the Multiple Correspondence Factors Analysis (AFCM). The step by step logistic regression was used for the multivariate explanatory analysis.

The descriptive bivariate analysis showed a significant variation of the discontinuity of obstetrical care by the parity, education, the ethnic group, the foregoing caesarean, the de jure place of residence, the department of residence, the accessibility and the quality of obstetrical services.

The Multiple Correspondence Factors Analysis, showed that in Benin, the women whose obstetrical care were discontinuous, are those who were socialised and living in rural areas: belonging to the Adja, Bariba, Dendi, Yoa and Lopka, Betamaribe and Peulh ethnic groups, living in the department of Atacora, Borgou, Mono and Zou and have made less than four antenatal visits; as they lives very far from the obstetrical health facilities centres (between 5 and 15 km or 15 km and more), and also with a low standard of living. Their ages were 35 years or more and having five or more children with no educational background.

The multivariate explanatory analysis revealed that the determinants factors of the discontinuity of obstetrical care are the ethnic group, the standards of living and the accessibility of obstetrical services. The refinement of the analysis by place of residence shows that in urban areas, only the ethnic group, the parity, education and the geographical accessibility and the quality of obstetrical services explain the discontinuity of obstetrical care whereas, in rural areas, it is explained by the childhood place of residence, the ethnic group, the parity, education and the accessibility and the quality of obstetrical services.

The step by step logistic regression showed that the women belonging to Bariba and Betamaribe ethnic groups were more likely to have a discontinuous obstetrical care, when living in urban areas than in rural ones. This result confirms our main theory which presumes that, before a woman searches for obstetrical care, she has to be predisposed for it, if not, despite all the facilities she will be offered; she will have a discontinuous obstetrical care. We also found that the standard of living did influence the discontinuity of obstetrical care through the accessibility and the quality of obstetrical services.

Keys words: Explanatory factors, discontinuity, obstetrical care, accessibility and quality, Africa, Benin.

* ² The WHO recommends at least four (4) antenatal visits during pregnancy.