Abstract
INTRODUCTION: The increasing inequality and multifaceted barriers to accessing maternal healthcare services play a significant role in the observed high maternal mortality ratios in sub-Saharan African (SSA) countries compared with other regions. Evidence is required to understand the relationship between barriers to healthcare access and the utilisation of maternal healthcare services. This study aims to assess the role of healthcare access barriers in the uptake of maternal health services in SSA. METHODS: We used a cross-sectional, demographic and health survey data from 14 SSA countries. We included 31 940 (31 553 weighted) reproductive-age women who had given birth in the year preceding the survey. Healthcare access barrier was an exposure variable and considered when a woman reported at least one of the following four concerns limiting access to healthcare services during illness: (1) difficulty obtaining permission to visit health facility, (2) financial challenges in covering healthcare expenses or treatment costs, (3) having significant travel distance to reach a health facility and (4) reluctance not wanting to visit facilities alone. We used χ(2) tests to select covariates and logistic regression to assess the association between healthcare access barriers and maternal healthcare service uptake. Propensity score matching (PSM) reduced selection bias by balancing observed characteristics between women with and without reported barriers. A one-to-one logit nearest neighbour matching method with bootstrap was used to estimate the average treatment effect on the treated (ATT) (women with access barriers) to antenatal care (ANC), health facility birth and postnatal care (PNC) services utilisation. Maternal education level, household wealth status, access to media, parity, COVID-19 pandemic period, geographical residence and country of residence were covariates used for matching. Post-matching sensitivity analysis and balance tests were conducted to assess the robustness of our PSM analysis. RESULTS: Almost three-fifths (60.2%) of women in the SSA (95% CI; 53.7% to 66.7%) reported barriers to accessing healthcare services. Barriers to accessing healthcare were associated with an 8-percentage point reduction in the likelihood of having a health facility childbirth (ATT: -0.08; SE: 0.016). However, there was insufficient evidence for differences in the uptake of ANC visit and PNC visit between the treatment (women with access barriers) and control groups. Post-matching tests confirmed that covariates were well balanced, and hidden biases were substantially reduced. CONCLUSION: The presence of barriers to healthcare access is negatively associated with the utilisation of health facility childbirth in SSA countries. These findings underscore the need for public health programmes that address the primary barriers to healthcare access, including financial constraints and physical accessibility, to enhance childbirth outcomes in health facilities.