Determinants of Non-Use of Postnatal Consultation Services in Urban Areas in Cotonou, Benin: A Qualitative Exploratory Study ()
1. Background
The postnatal period is the time interval between the birth of the baby and the sixth week (42 days) following delivery. It is a critical phase for the health of the mother and the newborn. However, this period is still marked by a high number of preventable deaths and complications. Postnatal care is a key component of the continuum of care from mother to child and remains essential for improving their well-being and achieving the goals of reducing maternal and neonatal mortality (OMS, 2022).
The World Health Organization (WHO) recommends four postnatal consultations for the mother and the newborn. The first consultation should take place within 24 hours of birth and the following three consultations are scheduled between 48 and 72 hours, between 7 and 14 days, and the fourth before the end of the six weeks after delivery (OMS, 2022).
Although 90.6% of deliveries take place in a health facility and 80.8% of live births are attended by skilled health personnel (INStaD, 2023), Benin still records a high maternal mortality ratio of 433 deaths per 100,000 live births, higher than the average in low‑income countries (INSAE & ICF, 2019). The results of the Multiple Indicator Cluster Survey show that 63.1% of newborns and 69.7% of women who gave birth in the city of Cotonou have never benefited from postnatal consultations after delivery, despite having access to health facilities (INStaD, 2023).
Several studies conducted in Benin (Dansou et al., 2017; Padonou et al., 2020; Agonnoude et al., 2023), have highlighted that the use of postnatal consultation services is associated with the mother’s level of education, household income, the occurrence of complications or caesarean delivery, health education, quality of reception in health facilities, and transport costs. However, these studies are quantitative or were conducted in rural settings and therefore do not allow a better understanding of the reasons, perceptions, and constraints experienced by mothers in urban areas. This qualitative study aims to fill this gap by exploring the determinants of non-use of postnatal consultation services in urban areas in Cotonou.
2. Methodology
2.1. Study Setting and Context
The city of Cotonou is located between 6˚20 and 6˚24 North latitude and 2˚20 and 2˚29 East longitude. It is situated at the extreme south of Benin, on the Atlantic Ocean. The city stretches approximately 10 km westward, where it borders the municipality of Abomey-Calavi, and 6 km eastward, towards the municipality of Sèmè-Kpodji. It is also bounded by Lake Nokoué to the north and the Atlantic Ocean to the south, which are its two main natural borders. It is the economic capital of Benin. Its population was estimated in 2025 at 1,394,296 inhabitants, with a density of 17,649 inhabitants/km2 compared with 124 inhabitants/km2 at the national level. The proportion of early pregnancies is 9.7% compared with 19% at the national level (INStaD, 2023).
The city of Cotonou has two national‑level referral centers: the University Teaching Hospital of Mother and Child Lagune (CHU-MEL), specialized in maternal and child health, and the Hubert Koutoukou Maga National University Hospital Center (CNHU‑HKM). In addition to these two centers, there are also two intermediate‑level referral centers (the district hospitals of Mènontin and Suru‑Léré) and more than one hundred health facilities (public health centers, clinics, and private hospitals) (Ministère de la Santé du Bénin, 2016). Data were collected in March 2025.
2.2. Participants and Data Collection
This study is of an exploratory qualitative nature and adopts a descriptive and interpretative approach to the obstacles to the use of postnatal care services in urban areas despite their availability. The study population consisted of midwives, community leaders, and women who had given birth within the last 42 days. The selection criteria were as follows:
For the midwives interviewed, they were practitioners of conventional medicine with at least six months of experience in the position, which enabled them to provide insights into the organization and conduct of postnatal consultations.
For community leaders, they were neighborhood chiefs who were members of the management committee of a health center in their locality.
For women who had given birth, the criteria were residing in the city of Cotonou and having given birth no more than 42 days prior to their participation, in order to ensure the relevance of the information collected.
A total of two midwives, two recently postpartum women, and two community leaders were interviewed using purposive sampling. The two women interviewed were aged 26 and 30. One was primiparous and the other multiparous. At the time of the interviews, they were 17 and 21 days postpartum, respectively. They had given birth at the Bethesda Hospital maternity ward and the Gbégamey Health Center. The community leaders were aged 48 and 52, while the midwives were 32 and 39 years old.
Participants were recruited from various neighborhoods and health facilities in the city of Cotonou to ensure a diversity of perspectives. The two postpartum women were recruited at the Bethesda Hospital maternity ward and the Gbégamey Health Center, respectively. The midwives practiced at the Gbégamey and Agla Health Centers, while the community leaders were from the Saint-Jean and Agla neighborhoods. Participants were contacted directly at their places of work or residence following a presentation of the study's objectives. Participation was voluntary, and no refusals were recorded among those invited. The small number of participants is due to the exploratory nature of the study, which aimed to gather diverse viewpoints to better understand the barriers to utilizing postnatal consultations in urban settings.
All participants were interviewed individually in order to collect usable data, particularly on sociocultural, economic, infrastructural, and organizational factors limiting postpartum women's access to postnatal care.
Three interview guides were developed: one for midwives, another for the postpartum women, and a third for community leaders. The guide for midwives focused on infrastructural and organizational factors related to postnatal care services. The guide for the postpartum women focused on access to care, costs, financial resources, geographical distance, travel time, and modes of transport.
2.3. Data Management and Analysis
The collected data were processed manually. First, the recorded interviews were transcribed verbatim and read multiple times to ensure thorough familiarization with the content. A thematic content analysis, following the method of Paillé and Mucchielli (2012), was then conducted. The process began with the manual coding of the transcripts, performed independently by two researchers. Each researcher identified units of meaning and assigned codes representing the main ideas expressed by the participants. Subsequently, the resulting codes were compared and discussed between the two researchers to resolve discrepancies and ensure the consistency of the analysis. Similar codes were then grouped into categories, which were progressively organized into main themes. These themes emerged from the data and reflect the primary determinants of the non-utilization of postnatal consultation services, including sociocultural, economic, infrastructural, and organizational factors. The transition from raw data to findings was thus carried out progressively, moving from participant quotes to codes, then to categories, and finally to interpretive themes.
Finally, an in-depth interpretation of the themes was conducted to understand the links between the various factors influencing the use of postnatal care in the urban environment of Cotonou. The comparison between the two researchers served to strengthen the reliability and credibility of the findings.
2.4. Ethical Considerations
The study was approved by the Local Ethics Committee for Biomedical Research of the University of Parakou (CLERB-UP), under reference number 1181/2025/ CLERB-UP/P/SP/R/SA. Data were collected with the verbal informed consent of the participants, obtained before each interview to facilitate participation and to adapt to the field conditions of a qualitative study. The interviews were recorded using a digital voice recorder, supplemented by field notes, and subsequently anonymized. Each participant was assigned an identification number used for the analysis to ensure the confidentiality of the information collected.
3. Results
The thematic analysis brought out three main themes that explain why some women in the city of Cotonou do not use postnatal consultation (PNC) services. This information came from health workers, neighborhood chiefs, and women who had given birth. The qualitative study showed that despite the awareness‑raising activities already implemented, there are still barriers related to lack of information, financial difficulties, and cultural beliefs or practices.
3.1. Ignorance and Perception
According to midwives, lack of information on the importance of PNCs is an important factor in the non-use of services. According to them, many women do not use PNC services because, for them, “there is nothing left to do” or they “feel well and the child has no problem” and they are not always aware of “possible risks such as uterine infections or complications in the newborn”. Health workers acknowledged that there has been an improvement thanks to awareness‑raising sessions, but “participation is still low, around 50%”. An observation is that women giving birth for the first time participated more in PNCs, often out of fear or under family influence. In contrast, those who had already had several children often relied on their past experience and downplayed the importance of consultations.
3.2. Socioeconomic Factors
Lack of money is often cited as the main reason for non-use of PNC services. Yet these consultations are generally free or inexpensive (around 1000 to 2000 CFA francs) and are already included in delivery fees. However, many women fear having to pay additional fees, such as for medicines or transport. As one participant expressed it: “They say the consultation is not expensive, but when we go there, they can still ask us to pay for medicines”. For another, the distance between the home and health centers was also a difficulty. The centers are located at the level of the districts and not in each neighborhood, which made access more difficult. Added to this were family responsibilities which limited the time available to attend consultations. Some women therefore preferred to turn to private clinics or traditional care that were closer. It was also observed that educated women or those with better financial means made greater use of health services. In contrast, women with little education or facing financial difficulties were more likely not to use them.
3.3. Cultural and Family Influences
According to health workers, traditions and religious beliefs also influenced the use of PNC services. “Others were discouraged by those around them, especially mothers‑in‑law or husbands, who felt there were other more important priorities”. However, this influence is not universal. Community leaders considered that the role of traditional practitioners was not as important as might be thought. But “the lack of staff in health centers and waiting times could discourage women from attending consultations”. However, the opening hours of services were not a major obstacle.
3.4. Emerging Recommendations
Respondents suggested several solutions to improve the use of postnatal consultation services. They suggested organizing home visits, making telephone reminders, giving small gifts (such as milk or diapers), strengthening awareness‑raising through radio, media, and community relay agents, and reducing costs. They also recommended better collaboration between health workers and community relay agents in order to strengthen women’s trust in health services.
4. Discussion
This qualitative study aimed to explore the determinants of non-use of postnatal consultation (PNC) services by women in urban areas in Cotonou. The results show that despite the availability of health facilities, several factors continue to limit the use of these services. The main barriers identified were lack of information, socioeconomic constraints, and certain cultural and organizational influences.
First, lack of information and women’s perceptions regarding the use of postnatal consultation services appear to be important factors in non-use. Similar findings have been reported in several studies conducted in sub-Saharan Africa, which show that women tend to view postnatal care as non‑priority when childbirth has occurred without complications (Sacks & Langlois, 2016; Wang et al., 2011). Yet the postnatal period remains a critical phase during which a large proportion of maternal and neonatal deaths occur (OMS, 2022). This highlights the need to strengthen health information and education strategies in order to improve knowledge of the risks associated with this period.
Second, socioeconomic constraints are also a major obstacle to the use of PNC services. Although consultations are generally inexpensive, some participants mentioned the fear of additional expenses related to medicines or transport. These findings are consistent with those of other studies conducted in low‑ and middle‑income countries, which show that the indirect costs of care can be an important barrier to the use of maternal health services (Azuh et al., 2015; Gabrysch & Campbell, 2009). In addition, the distance between the home and health facilities, as well as family responsibilities, may also limit women’s availability to attend consultations. This situation shows that even in urban areas, the geographical and financial accessibility of services remains a challenge for the use of postnatal care.
Finally, the results of this study highlight the influence of the social and cultural environment on the decision to seek postnatal consultation services. In some cases, women may be influenced by those around them, particularly husbands or mothers‑in‑law, who do not always consider postnatal consultations a priority. Studies conducted in several low‑ and middle‑income countries, including African countries, have shown that decisions related to maternal health are often influenced by social norms and family members (Story et al., 2012; Titaley et al., 2010). These findings suggest that interventions aimed at improving the use of maternal health services should also involve families and community leaders.
5. Limitations
The relatively small number of participants in this study limits the generalization of the results. Moreover, the study does not necessarily reflect the situation in other urban or rural contexts in Benin, since it was conducted only in the city of Cotonou. Despite these limitations, this research provides important qualitative insights into the barriers to the use of postnatal consultations and can help guide interventions to improve maternal and neonatal health.