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.