Burkina Faso

Effects of terrorist attacks on access to maternal healthcare services: a national longitudinal study in Burkina Faso

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Thomas Druetz, Lalique Browne, Frank Bicaba, Matthew Ian Mitchell, Abel Bicaba

Abstract

Introduction Most of the literature on terrorist attacks’ health impacts has focused on direct victims rather than on distal consequences in the overall population. There is limited knowledge on how terrorist attacks can be detrimental to access to healthcare services. The objective of this study is to assess the impact of terrorist attacks on the utilisation of maternal healthcare services by examining the case of Burkina Faso.

Methods This longitudinal quasi-experimental study uses multiple interrupted time series analysis. Utilisation of healthcare services data was extracted from the National Health Information System in Burkina Faso. Data span the period of January 2013–December 2018 and include all public primary healthcare centres and district hospitals. Terrorist attack data were extracted from the Armed Conflict Location and Event Data project. Negative binomial regression models were fitted with fixed effects to isolate the immediate and long-term effects of terrorist attacks on three outcomes (antenatal care visits, of facility deliveries and of cesarean sections).

Results During the next month of an attack, the incidence of assisted deliveries in healthcare facilities is significantly reduced by 3.8% (95% CI 1.3 to 6.3). Multiple attacks have immediate effects more pronounced than single attacks. Longitudinal analysis show that the incremental number of terrorist attacks is associated with a decrease of the three outcomes. For every additional attack in a commune, the incidence of cesarean sections is reduced by 7.7% (95% CI 4.7 to 10.7) while, for assisted deliveries, it is reduced by 2.5% (95% CI 1.9 to 3.1) and, for antenatal care visits, by 1.8% (95% CI 1.2 to 2.5).

Conclusion Terrorist attacks constitute a new barrier to access of maternal healthcare in Burkina Faso. The exponential increase in terrorist activities in West Africa is expected to have negative effects on maternal health in the entire region.

Key questions

What is already known?

Improvements in access to healthcare are fragile in politically unstable countries such as Burkina Faso, and are likely to disappear if new barriers are introduced or former barriers are reinstituted.

The primary factors that continue to limit women’s access to healthcare after user fee abolition are distance to health facilities, low quality of care and informal costs; however, the extent to which insecurity generated by terrorist attacks presents a new type or barrier to maternal healthcare access remains under-investigated.

What are the new findings?

Our findings suggest that terrorist attacks have immediate repercussions on different indicators of maternal care, notably the number of antenatal care visits, assisted deliveries and cesarean sections.

This study also reveals that repeated attacks aggravate insecurity and are further detrimental to maternal healthcare access in affected regions.

What do the new findings imply?

Regional insecurity needs to be recognised and investigated by the global health research community as a barrier to maternal healthcare and universal health coverage.