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. 2023 Oct 2;22(1):203.
doi: 10.1186/s12939-023-02015-0.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

Anteneh Asefa  1 , Samson Gebremedhin  2 , Tiara Marthias  3   4 , Herfina Nababan  5 , Aliki Christou  6 , Aline Semaan  6 , Aduragbemi Banke-Thomas  7   8 , Hanani Tabana  9 , Fadhlun M Alwy Al-Beity  10 , Jean-Paul Dossou  11 , Keneni Gutema  12 , Thérèse Delvaux  6 , Catherine Birabwa  13 , Mardieh Dennis  14 , Fassou Mathias Grovogui  15 , Barbara McPake  3 , Lenka Beňová  6
Affiliations

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

Anteneh Asefa et al. Int J Equity Health. .

Abstract

Background: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.

Methods: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.

Results: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.

Conclusions: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Keywords: Antenatal care; Demographic and health survey; Facility-based childbirth; Inequality; Maternal continuum of care; Postnatal care; Sub-Saharan Africa.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Countries included in this study and DHS sample size
Fig. 2
Fig. 2
Percentage of women completing primary maternal continuum of care, by wealth index, by country
Fig. 3
Fig. 3
Concentration indices of primary maternal continuum of care across countries (0 = equality)
See this image and copyright information in PMC

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