A multilevel analysis of social determinants of skilled birth attendant utilisation among married and cohabiting women of Madagascar

Ebenezer Kwesi ARMAH-ANSAH, Benedicta BAWA*, John DINDAS, Eugene BUDU, Bright Opoku AHINKORAH, Edward Kwabena AMEYAW

*Corresponding author for this work

Research output: Journal PublicationsJournal Article (refereed)peer-review


Maternal mortality ratio (MMR) in Madagascar is 392 deaths per 100 000 live births, and this is a major public health concern. One of the strategies for reducing MMR and achieving target 3.1 of the Sustainable Development Goals (i.e. reducing the global MMR below 70 per 100 000 live births) is the utilisation of skilled birth attendants (SBAs). This analysis examined the prevalence and social determinants of SBA utilisation among married and cohabiting women of Madagascar.

Data from the 2021 Madagascar Demographic and Health Surveys was analysed on a weighted sample of 6997 married and cohabiting women. A multilevel regression was carried out to determine the social determinants of utilising SBAs. The results are presented as odds ratios (ORs) associated with 95% confidence intervals (CIs) and a p-value <0.05 to determine the significant associations.

The prevalence of SBAs among married and cohabiting women of Madagascar was 64.4% (95% CI 0.62 to 0.68). In model 3 of the multilevel regression, women 35–39 y of age (adjusted OR [aOR] 1.86 [95% CI 1.30 to 2.60]), women with secondary/higher education (aOR 1.67 [95% CI 1.32 to 2.10]), women whose partners had secondary/higher education (aOR 1.58 [95% CI 1.25 to 1.99]), cohabiting women (aOR 1.33 [95% CI 1.07 to 1.65]), women who had four or more antenatal care visits (aOR  2.05 [95% CI 1.79 to 2.35]), female household head (aOR 1.44 [95% CI 1.06 to 1.95]), Muslims (aOR 1.58 [95% CI 0.71 to 3.53]), those of the richest wealth index (aOR 4.32 [95% CI 2.93 to 6.36]) and women who lived in communities with high literacy levels (aOR 2.17 [95% CI 1.57 to 3.00]) had higher odds of utilisation of SBA.

This current analysis revealed low SBA utilisation among married and cohabiting women in Madagascar. The analysis points to the fact that understaffing and inaccessibility of health facilities remain major contributors to the low utilisation of SBAs. The findings call on the government and stakeholders in Madagascar to consider implementing programs that will empower women and focus on disadvantaged groups. These programs could include providing free maternal healthcare services to all pregnant women and intensifying health education programs that target women and their partners with no formal education.
Original languageEnglish
Number of pages11
JournalInternational Health
Publication statusE-pub ahead of print - 27 Nov 2023

Bibliographical note

We are grateful to MEASURE DHS for granting access to the datasets used in this study.

© The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.


  • Demographic and Health Surveys (DHS)
  • determinants
  • Madagascar
  • multilevel analysis
  • skilled birth attendant
  • utilisation


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