Discussion
This study has aimed to contribute towards the growing evidence of community-based primary healthcare programs’ effects on maternal and child health and survival in a rural poor context. Pregnancy-related complications are among the leading causes of maternal morbidity and mortality. Poor access to maternal services is a known contributor to adverse pregnancy outcomes . Previous studies have shown that community-based primary healthcare improves access to a wide range of maternal and child healthcare services . Therefore, this study commences with the hypothesis that GEHIP’s community-based healthcare program would have a positive impact on the reduction of adverse pregnancy outcomes as well as improving equity in those outcomes.
Results indicate that adverse pregnancy outcome reduced from 12% to 7% within the intervention group while the non-intervention groups experience only a 1% reduction from 11% to 10%. Difference-in-difference regression analysis shows that GEHIP had a significant effect in the reduction of adverse pregnancy outcomes (DiD= -0.046; p-value= 0.010). It was found that older mothers, single mothers and lower parity mothers were more likely to have adverse pregnancy outcomes compared to their counterparts. Previous studies have consistently shown older mothers are more likely to have adverse pregnancy outcomes compared to younger mothers, it is therefore not surprising that the same trend was found in this study . Single mothers and nulliparous mothers have also been documented to have poor birth outcomes . Interestingly, socio-economic-related variables like household wealth index and maternal educational status were not significantly associated with adverse pregnancy outcomes. A national cohort study in England found wide socioeconomic and ethnic inequalities in adverse pregnancy outcomes. Indeed, low socioeconomic status has long been associated with poor health-seeking behaviour and adverse health outcomes
It is noted that resource allocation to community-based healthcare programs is often backed by not only the assumption that mothers and children will benefit by the accessibility to healthcare, but also the potential equity effects of making services available at convenient locations in remote communities. General improvements in health outcomes may sometimes deepen health inequalities between the wealthy and the poor as better-off households often have improved access to new innovations and the economic means to get them . To this end, this study set off to further examine if changes in pregnancy outcomes as a result of GEHIP intervention have contributed to any changes in socio-economic inequalities.
Household wealth index and mothers’ educational attainment were used as proxy socioeconomic indicators. Univariate analysis shows a reduction in adverse pregnancy outcomes for the disadvantaged groups (the poor and those with no formal educational attainment). However, further analysis controlling for confounders found that the average marginal effect of wealth and maternal education is not statistically significant. Thus, GEHIP neither improved nor widen socioeconomic inequalities in pregnancy outcomes.
The inverse equity hypothesis proposed by Victora et al postulates that public health interventions initially often reach those in higher socioeconomic status first thus increasing inequality and this later level up as the rich achieve new minimum levels of outcomes and the poor also gain greater levels of access to interventions . Going by this hypothesis, and noting that community-based primary healthcare program was made a national policy in Ghana in the year 2000 while GEHIP commences almost ten years later, then the inverse equity hypothesis is at play and the findings of this study is in line with the later stage of this process.