Interrelationships among key Reproductive Health indicators in Sub-Saharan Africa

Abstract Introduction Indicators of reproductive health (RH) services, outputs, outcomes and impacts are expected to be related with each other and with key social determinants. As the provision of RH services is usually integrated, the effort expended to improve one component is also expected to affect the other components. There is a lack of evidence-based models demonstrating the interrelationships among these indicators and between RH indicators and social determinants. Objective To examine interrelationships among key RH indicators and their relationship with key social determinants in Sub-Saharan Africa (SSA). Method This study used data from the most recent demographic and health survey conducted during the period from 2010 to 2016 in 391 provinces of 29 SSA countries. We focused on seven RH indicator — antenatal care, skilled birth attendance, postnatal care, contraceptive prevalence rate (CPR), ideal number of children, birth interval and total fertility rate (TFR), along with selected socio-demographic indicators. The unit of analysis was sub-national, at provincial level. Structural equation modelling was used to examine the strength of interrelationships among the indicators based on the total standardized effect sizes. Significance tests and 95% confidence intervals for the total effects were presented using a bias-corrected bootstrap method. Results Women’s literacy rate, at the centre of the model, has direct connections with all the RH indicators included in the final model. The strongest relationship was observed between women’s literacy rate and CPR with a total standardized (std.) effect size of 0.79 (95% CI: 0.74, 0.83). RH indicators are interrelated directly and/or indirectly. A strong direct effect was also observed in the relationship between CPR and birth interval (β=0.63, 95%: 0.50, 0.77) and the model suggests that the reported ideal number of children is a key predictor of birth interval (Std. effect size=-0.58, 95% CI: -0.69, -0.48) and TFR (Std. effect size=0.52, 95% CI: 0.38, 0.62). Conclusion RH indicators are strongly interrelated and are all associated with women’s literacy. The model of interrelationships developed in this study may guide the design, implementation and evaluation of RH policies and programs.