Antenatal care services in Benin and Tanzania 2021/2022: an equity analysis study

Abstract

Introduction: Antenatal care (ANC) interventions improve maternal and neonatal outcomes. However, access to ANC may be inequitable due to sociocultural, monetary and time factors. Examining drivers of ANC disparities may identify those amenable to policy change.

Methods: We conducted an ANC services equity analysis in selected public facilities in Geita, Tanzania, where most services are free to the end-user, and Atlantique, Benin, where every visit incurs user fees. Data on total ANC contacts, quality of care (QoC) indicators and wait times were collected from representative household surveys in the catchment of 40 clinics per country and were analysed by education and wealth. We used indices of inequality, concentration indices and Oaxaca-Blinder decompositions to determine the distribution, direction and magnitude of inequalities and their contributing factors. We assessed out-of-pocket expenses and the benefit incidence of government funding.

Results: ANC clients in both countries received less than the recommended minimum ANC contacts: 3.41 (95% CI 3.36 to 3.41) in Atlantique and 3.33 (95% CI 3.27 to 3.39) in Geita. Wealthier individuals had more ANC contacts than poorer ones at every education level in both countries; the wealthiest and most educated had two visits more than the poorest, least educated. In Atlantique, ANC attendees receive similar QoC regardless of socioeconomic status. In Geita, there are wide disparities in QoC received by education or wealth. In Atlantique, out-of-pocket expenses for the lowest wealth quintile are 2.7% of annual income compared with 0.8% for the highest, with user fees being the primary expense. In Geita, the values are 3.1% and 0.5%, respectively; transportation is the main expense.

Conclusions: Inequalities in total ANC visits favouring wealthier, more educated individuals were apparent in both countries. In Atlantique, reduction of user-fees could improve ANC access. In Geita, training and equipping healthcare staff could improve QoC. Community health services could mitigate access barriers.

Figure 1. Comparison of selected antenatal care (ANC) indicators by country wealth and education. E0, No education; E1, Primary education; E2, Secondary education; E3, Higher education; Q, Wealth quintile. (A) Mean number of ANC visits completed, proportion of women who had urinalysis, proportion of women who had blood pressure measurement, mean number of IPTp doses, mean distance travelled and mean waiting time by location and wealth quintile. (B) Mean number of ANC visits completed, proportion of women who had urinalysis, proportion of women who had blood pressure measurement, mean number of IPTp doses, mean distance travelled and mean waiting time by location and level of education.

Figure 2. Marginal analysis, ANC attendance by education and wealth. The marginal analysis shows the effect of wealth on ANC contacts while holding education constant. In this case, wealthier people have more ANC contacts across different education levels than poorer ones. ANC, antenatal care.

Figure 3. Inequality decomposition analyses for total ANC contacts: Benin and Tanzania. This figure shows the contribution of different variables to inequalities in ANC contacts using various decomposition methods—Cotton, Neumark and Reimers. ANC, antenatal care.

Figure 4. Out-of-pocket (OOP) costs for antenatal care as a proportion of simulated household annual income. While OOP costs as a proportion of total annual household income are relatively lower in the higher wealth categories in both countries, the lowest wealth group spends a disproportionate percentage of their annual household income on healthcare costs, particularly in Tanzania. In Benin, the lowest quintiles spend around 2.7% of their annual income as OOP expenditure on ANC and childbirth services, whereas the highest quintile spends only 0.8%. The corresponding figures in Tanzania are 3.1% and 0.5%, respectively. ANC, antenatal care.