This study reports the prevalence of health insurance ownership among Jordanian women across various socio-demographic backgrounds in addition to the association between health insurance coverage and the three key maternal health services; timing of first ANC visit, meeting the recommended four ANC visits and having a skilled birth attendance. This is the first comprehensive study to discuss the association between health insurance ownership and maternal health utilization in Jordan using data from 2017 to 18.
Overall, 38.2% of the study participants reported having no health insurance coverage in the present study. Findings on the prevalence of health insurance coverage is similar but slightly higher than the prevalence obtained in a recent study, where the coverage of health insurance was about 27% [26]. The possible reason for the differences in findings could be the study population and sample size. With MHC services utilization, 12.5, 23.2, and 10.1% respectively, failed to make early first antenatal care visit, complete the recommended number of antenatal care visits and have their delivery attended by a skilled worker. Findings on the prevalence of MHC services utilization is in line with previous studies [27, 28]. The high prevalence of MHU in the country could be attributed to the improvement in maternal healthcare through universal health coverage and the implementation of health insurance in the country [5, 6] and general improvement in access to MHC services utilization through the provision of health facilities and presence of health professionals in those health facilities [29].
After controlling for the socio-demographic factors, we found that health insurance coverage was associated with increased odds of timing of first ANC visits and recommended completion rate of ANC visits. Similar findings were obtained in previous studies [18,19,20,21]. The possible reason for the finding could be that health insurance coverage reduces the rates of out-of-pocket payments associated with the use of MHC services utilization. Such payments may pose as financial barriers to women when accessing maternal healthcare services. Interestingly, women who were covered by health insurance were less likely to use skilled birth attendance during delivery. This finding is contradicts the findings of previous studies that found a positive association between health insurance coverage and skilled birth attendance [30, 31]. Further studies are needed to unearth the possible reasons for the negative association between health insurance coverage and skilled birth attendance during delivery in Jordan.
Age, wealth index, region, and parity were all positively associated with timely ANC initiation. This result ties well with a study that examined determinants of ANC attendance among Jordanian women living in disadvantaged communities [32]. Being insured gives women a valid reason to make use of available ANC services. As hypothesized, being insured does yield uptake of maternal services as women are not left financially strained in doing so. Possessing higher education informs women on the necessity of initiating an ANC visit within the first trimester. Younger women and women with higher parity also adhered to the recommended timing of ANC initiation. There was regional variation in this study among Jordan’s twelve governotes. Aljoun, Aquaba and Irbid all fared high in proper ANC initiation while Madaba scored the lowest. This study recommends looking at the strategies that have been effective in promoting a timely ANC visit in the former three governorates. Occupation, marital status, area of residence and wealth index had no influence on the timely starting of ANC visits in this study. Considering that ANC is provided free of charge in Jordan, this may explain the non-significant associations [32].
This analysis found evidence for education, marital status, wealth index and parity influencing respondents to completing the four recommended ANC visits. As observed with the first key maternal health service, educated women are more informed of pregnancy-related risks and will thus adhere to completing the required amount of ANC visits in comparison to lower and non-educated women. In line with other studies [5, 16, 17], education proves to be a strong determinant in uptake of maternal health services. Being employed was a positive indicator for women fulfilling advised ANC visits as having a stable job grants financial security, thus allowing expectant mothers to be able to afford maternal services. Married women were more likely to meet the four standard visits than their single counterparts. This can be attributed to married women receiving financial and emotional support from their spouses to partake in maternal services. Women placed on the richer and richest category on the wealth index met the ANC visit completion rate. Above average financial standing readily equips women to be able to afford these services. Lastly, parity was positively associated with ANC visits; this can be owed to women having more experience and acquired knowledge from prior pregnancies. Once again, regional variation was observed among the dozen governorates. The Ma’an region saw the lowest completion rate, in which less than three-quarters of participants failed to meet the recommended ANC visits. Associations with health insurance coverage, age and area of residence did not reach statistically significant levels in the present analysis. As with the preceding section, this may be attributable to Jordan offering ANC services at no charge.
The findings in this study revealed that area of residence, wealth index and parity influenced the study participants to have a skilled birth attendance. Educated expectant mothers are likely to be aware of birthing-risks and may opt to have their delivery under the care of a skilled worker [17,18,19,20,21, 33]. As discussed in the former sections, being employed and married comes with the benefit of greater financial security and thus promotes use of maternal services. Urban residents reported higher rates of skilled birth attendance than women residing in rural areas. This can be owed to urban regions having a greater prevalence of maternal facilities due to greater demand. As seen earlier, higher parity comes with more experience and thus women would be more familiar with the birthing process and could recognize the benefits of receiving a skilled birth attendance. Of intriguing note, single women reported a higher proportion of professional deliveries than their married and insured counterparts. This seemingly exceptional observation was also documented in a similar study [33] which stated that women living independently, and women-head households exercise greater autonomy and decision-making power with regard to using maternal health care services. A comprehensive community-level interventions that consider residential homogeneity regarding infrastructure (e.g., health facilities, roads) and socioeconomic empowerment (e.g., educational and vocational training) could promote women health-promoting behaviours and their access to maternal healthcare services.
Prior studies have revealed that there are significant disparities with respect to the quality of health services between the health sector institutions and between Jordan’s various governorates [16, 17, 32]. This study was no exception. With skilled birth attendance, Mafraq and Jerash scored poorly in comparison to Balga and Amman. The consistent disparities across the governorates is likely due to certain regions being more rural and having a hasher desert climate than others which makes having equipped maternal facilities and trained health workers more challenging. Thus, factors other than health insurance coverage, such as availability, access and quality of maternal services, may pose as the larger underlying issue to MHC services utilization. For example, a qualitative study conducted on Jordanian women regarding their delivery experience reported that maltreatment by health providers impacted their decision-making in choosing to have a midwife over a skilled birth attendant for future pregnancies [34]. Concerted efforts from the regional and national government should be enacted to implement strategies to promote MHC services utilization to bridge the disparity between the advanced governorates and the disadvantaged ones.
Strengths and limitations
The study used nationally representative data from the DHS, and therefore the findings are generalizable in the study area. However, results of the present study should be discussed in light of its limitations. Firstly, the primary source of the information collected from the study participants was through self-report. This data collection method allows for recall bias which could have resulted in underestimation or overestimation of past experiences, especially given that the chosen variable for parity included a span of 5 years. Second, the study was limited to the variables that were available on the DHS questionnaire; other potentially relevant socio-demographic factors, such as affiliated religion, were not analyzed. Lastly, this study excluded respondents that were not of Jordanian nationality. Given Jordan’s diverse demographic make-up, most notably Syrian and Palestinian refugees that have sought asylum in the country in recent decades [7, 8], it would be of significance to explore this population’s health insurance status and utilization of the essential maternal services. In terms of study design, the study used a cross-sectional research design that limits causal relations between the studied variables. Findings of the study cannot be generalized to all women of reproductive age but only childbearing women. Finally, we acknowledge that there might be some health system factors that affect the variance in the coverage of insurance, and hence MHC services utilization. However, we could not assess this since the dataset does not provide data on it.