Creating Reproductive Health Behavioral Profiles for Women of Reproductive Age in Niger Using Cross-Sectional Survey Data: A Latent Class Analysis

Niger has the highest fertility rate in the world at 6.8 births per woman as well as a high maternal mortality rate (509 maternal deaths per 100,000 live births) and high child mortality rate (80 child deaths per 1,000 live births). Contributing to these poor health indicators are low levels of utilization of antenatal care (ANC), facility-based births, and family planning (FP), where, in Niger, only 33% of women who had given birth in the past 5 years have attended at least four ANC visits, 60% of births occurred at a health facility, and only 18% of married women were using modern FP. Improving the health-seeking behaviors and subsequent utilization of these critical health services can yield much-needed gains in maternal and newborn health in Niger. Adequate ANC allows for the diagnosis and treatment of pregnancy-related complications, and facility-based deliveries enable the use of life-saving procedures when delivery complications occur. As such, both ANC and facility-based deliveries are associated with reduced infant mortality. Additionally, an increase in the use of modern FP can reduce maternal mortality by reducing the risk of unsafe abortion, delaying the first pregnancy among young women with premature pelvic development, and decreasing risks associated with high parity and closely spaced pregnancies. Understanding the specific determinants and barriers to health-seeking for reproductive and maternal health services are critical to developing programs that can best address the needs of the community. Several factors can influence health-seeking behaviors for these services, including socioeconomic variables (e.g., education, wealth), as well as determinants outlined in the theory of planned behavior, which include knowledge, perceived self-efficacy, attitudes, and perceived community gender and other social norms. One systematic review on the determinants of ANC utilization in sub-Saharan Africa found that in addition to socioeconomic factors, knowledge of the dangers of pregnancy and the number of recommended ANC visits, as well as positive attitudes toward ANC utilization, were key predictors of adequate ANC use, particularly for those in rural areas where knowledge levels are lower. To address the health-seeking behavior and health services utilization challenges experienced in Niger, the US Agency for International Development's (USAID) Resilience in the Sahel Enhanced (RISE) initiative was initially conceived in 2012 as a response to a pattern of recurring severe droughts and other stressors undermining health development in the region. Focused on the chronically vulnerable populations in Niger and Burkina Faso, the RISE program has strengthened the capacity of state institutions and local governance, increased sustainable economic wellbeing, and improved health and nutrition. The subsequent RISE II program (2018-2023) builds on these accomplishments and has expanded to investments aimed at improving priority behaviors in maternal, newborn, and child health (MNCH), FP, and water, sanitation, and hygiene (WASH) through an integrated social and behavior change (SBC) strategy. Effective SBC interventions incorporate audience segmentation, which refers to the practice of dividing an audience into subgroups based on demographic, psychographic, and/or behavioral factors to develop tailored SBC approaches that are most likely to resonate with the audience subgroup. Latent class analysis (LCA) identifies a set of subgroups based on patterns of responses across study participants in survey data and is increasingly being applied in social and behavioral science research to understand risk profiles in the health field. LCA allows us to move beyond singularly focusing on one characteristic at a time (e.g., age) and instead finds relationships within the data that provide a more nuanced understanding of audience profiles using multiple characteristics at the same time.