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. 2024 Jan 22;9(1):e013029.
doi: 10.1136/bmjgh-2023-013029.

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

Manuela Straneo  1   2   3 , Claudia Hanson  4   5   6 , Thomas van den Akker  2   7 , Bosede B Afolabi  8 , Anteneh Asefa  3 , Alexandre Delamou  9   10 , Mardieh Dennis  11 , Luis Gadama  12 , Nyika Mahachi  13 , Welcome Mlilo  14 , Andrea B Pembe  15 , Jovanny Tsuala Fouogue  16 , Lenka Beňová  3   17
Affiliations

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

Manuela Straneo et al. BMJ Glob Health. .

Abstract

Introduction: Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

Methods: Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

Results: This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

Discussion: Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Keywords: Epidemiology; Health systems; Maternal health; Obstetrics.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
A - percentage of facility births, B - percentage of hospital births, among women with a live birth in the surveys’ recall period in rural settings of 18 SSA countries with a recent DHS survey.
Figure 2
Figure 2
Equiplots of hospital births in rural settings of 18 SSA countries with a recent DHS survey, by: A. wealth among all women, B. parity (0 and high parity ≥5), C. wealth among women at parity 0, D. wealth among women at high parity (≥5).
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References

    1. United Nations . Sustainable Development Goals 2021, Available: https://unsdg.un.org/ [Accessed 5 Nov 2021].
    1. UNICEF . Data by topic and country no date, Available: https://data.unicef.org/resources/
    1. WHO . Trends in maternal mortality 2000-2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization, 2023.
    1. Houweling TAJ, Ronsmans C, Campbell OMR, et al. . Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bull World Health Organ 2007;85:745–54. 10.2471/blt.06.038588 - DOI - PMC - PubMed
    1. Black R, Laxminarayan R, Temmerman M, et al. . Reproductive, maternal, newborn, and child health: disease control priorities. In: Black RE, Laxminarayan R, Temmerman M, eds. Levels and Causes of Maternal Mortality and Morbidity. The International Bank for Reconstruction and Development / The World Bank (c) 2016 International Bank for Reconstruction and Development / The World Bank: Washington (DC), 11 April 2016. 10.1596/978-1-4648-0348-2 - DOI