As shown by our results, access to reproductive health services varies among women of reproductive ages. A large proportion of women in Ghana and Nigeria have poor access to family planning services. Most women do not have access to modern contraceptives. They use traditional birth control methods or do not have the means for needed services. These differences in access to maternal health services in both countries reflect a broader gap between women who access antenatal care at government hospitals, government facilities for childbirth with a physician present, and the low access group of women limited to services such as government health posts without skilled assistance during childbirth, or antenatal care private vendors. This confirms that among women of reproductive ages in Ghana and Nigeria, there exists unequal access to reproductive health services.
According to Gulliford, et al. 6, sub-population-specific needs of care arise when unmet needs lead to unequal healthcare utilization or access. This suggests a dysfunctional organization structure that creates constraints to preventive and medical procedures provided by well-trained professional 3 17 21.
Our results show that educational attainment is associated with access to family planning and maternal health services. Low educational attainment reduces the ability to overcome access barriers, particularly to maternal health services. This finding supports similar results in other studies on the importance of education in improving access to reproductive health services 9–11 22. Our results indicate that among women with low education, some intend to use contraceptives later while others use traditional contraceptive methods of family planning. Notably, the group with poor access to family planning services for a large part consists of women who have no future intention of contraceptive use. This could be due to lower-educated women being less able to act on their intentions due to difficulty in overcoming access barriers or limited knowledge about the benefits of family planning 23. The connection between education and socioeconomic status could also explain this observation; low education attainment, usually implies less access to resources 9 24 25. The result further confirms what is known about the social stratification and its relationship fostering inequalities 8.
Results suggest that wealth/finance related inequality in access to reproductive health services is prominent in Nigeria and Ghana. Considering finance related inequality between the two countries, we find that women without insurance coverage in Ghana are less likely to access family planning services. This is dissimilar to their counterparts without insurance in Nigeria; women in Nigeria who have poor-access to family planning opt for services such as traditional methods of contraception. These findings are consistent with other research on the use of family planning services in the countries and other parts of Africa 9. This can be partially attributed to inaccessibility of family planning services through a cost-reducing scheme inadvertently increasing the financial burden on household’s preference for traditional contraceptives among some women 26. Other research also found a situation similar to Ghana among women in Burkina Faso and concluded that affordability of insurance premium varies by household income 12. The poor access to reproductive health services in any of the wealth quintilesin Nigeria is expected considering the lack of insurance. The low coverage of insurance schemes such as the NHIS, particularly among informal workers or uneducated women, magnifies the effect of household wealth 16 17.
There is an association between maternal occupation and access to maternal health service in both countries. Other studies have reported various associations 13 21 22. However, where associations between maternal occupation and access to reproductive health services are observable, disparity by type is not unusual 21. The results suggest that women in Nigeria are predisposed to any type of maternal health services compared with Ghana: access among Ghana women was only observed within the higher-access and low-access clusters.
It is possible that the cost of maternal health services available to women in Ghana (through the free maternal care policy) can be (or has to be) endured by women themselves in Nigeria 27 28. In the five maternal health services access groups observed, women of all occupational type belong to at least one of five maternal health services access group available. Conversely, women in Ghana (except sales) either belong to two of five - the high- or poor-access group—and are likely to access maternal health services in either group. Out-of-pocket payments for health has been consistently high in Nigeria compared with Ghana while insurance coverage is better in Ghana, particularly in the informal sector 26 29.
This study has some limitations that need to be acknowledged. There was not much variation in some response variables and they had to be excluded from the analysis. The inclusion of country-specific variables helps to better reflect the women’s situation but this also creates some dissimilarities in the country analytical models.