Objectives: This study examined prenatal care use among women in sub-Saharan Africa, focusing on the West African region. The primary analysis examined variations by individual and national measures of wealth and literacy. Secondary analyses examined whether adequate prenatal care is associated with lower risk of infant mortality for women in all income groups. Methods: Analyses used data from Demographic and Health Surveys completed between 2006 and 2010 in Benin, Burkina Faso, Ghana, Guinea, Liberia, Mali, Niger, Nigeria, Senegal and Sierra Leone, to examine prenatal care use among women with a recent live birth (58,512 respondents). Chi-square tests, multivariate logistic regression and proportional hazards regression were used to test study hypotheses. Adequate prenatal care was defined by the World Health Organization's recommendations of at least four prenatal care visits beginning in the first trimester, with at least one visit with a skilled health professional. Individuals were grouped into wealth quintiles based on household assets. Models were adjusted for the following predisposing, enabling and need characteristics, which were available for all countries: age, parity, marital status, religion, pregnancy wantedness, rural/urban residence, occupation, and involvement in decision-making at home. Results: In multivariate analyses, women who could not read had lower odds of adequate prenatal care compared to literate women (odds ratio, OR 0.70; 95% confidence interval, CI 0.66-0.74). Similarly, women in the poorest quintile were less likely to receive adequate prenatal care compared to women in the wealthiest quintile (OR 0.31; CI 0.28-0.34). Each one-point increase in the literacy rate among women was associated with 4% higher odds of having adequate prenatal care (OR 1.04; CI 1.01-1.08). The effect of prenatal care on infant mortality varied significantly by wealth quintile. In the wealthiest quintile, women with adequate prenatal care had 34% lower risk of infant death compared to women with inadequate or no care (hazard ratio, HR 0.66; CI 0.51-0.85). However, the effect of adequate prenatal care on infant death was not significant for women in other wealth quintiles. Discussion: Findings from this study suggest that illiteracy and poverty may both increase the likelihood of inadequate prenatal care, even when use of prenatal care is high. Findings highlight effects of wealth disparities on the use of prenatal care and on infant mortality. These effects suggest that additional interventions focused on reducing poverty may be useful for improving maternal and child health in this region. Policymakers should consider mechanisms for increasing access to skilled care by addressing barriers faced by poor, less educated women.
