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

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.

Keywords: health services research; maternal health; other study design; public health.

Figure 1

Trends in violent events in Burkina Faso, 2013–2019.

Figure 2

Map of the communes in Burkina Faso, by terrorist activity level, 2013–2018.

Figure 3

Predicted trends (with 95% CI) of the three study outcomes in the commune of Tongomayel, 2013–2018. Trends in blue are predictions with no attack in the commune (natural trends). Trends in orange are predictions based on the actual number and timing of attacks experienced by the commune of Tongoyamel. (A) Trends in the number of cesarean sections. (B) Trends in the number of assisted deliveries. (C) Trends in the number of antenatal care visits.