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Asefa A, Gebremedhin S, Marthias T, Nababan H, Christou A, Semaan A, Banke-Thomas A, Tabana H, Al-beity FMA, Dossou JP, Gutema K, Delvaux T, Birabwa C, Dennis M, Grovogui FM, McPake B, Beňová L. Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries. Int J Equity Health 2023; 22:203. [PMID: 37784140 PMCID: PMC10544383 DOI: 10.1186/s12939-023-02015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
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.
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Affiliation(s)
- Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Tiara Marthias
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
- Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Herfina Nababan
- Institut für Public Health und Pflegeforschung, Universität Bremen, Bremen, Germany
| | - Aliki Christou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fadhlun M. Alwy Al-beity
- Department of Obstetrcis/Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine Et en Démographie, Cotonou, Bénin
| | - Keneni Gutema
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Fassou Mathias Grovogui
- Centre National de Formation Et de Recherche en Santé Rurale (CNFRSR), Maferinyah, Forécariah Guinea
| | - Barbara McPake
- School of Population and Global Health, Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Barillas W, Lee H. Maternal oral health framework: integration of oral health into perinatal care. J Public Health Policy 2022; 43:696-702. [PMID: 36195649 PMCID: PMC9531211 DOI: 10.1057/s41271-022-00366-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Wendy Barillas
- grid.59734.3c0000 0001 0670 2351Icahn School of Medicine, Mount Sinai, New York, USA
| | - Hyewon Lee
- Seoul National University, School of Dentistry, Seoul, South Korea. .,Seoul National University, Dental Research Institute, Seoul, South Korea.
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Mothupi MC, De Man J, Tabana H, Knight L. Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa. PLoS One 2021; 16:e0252182. [PMID: 34033670 PMCID: PMC8148336 DOI: 10.1371/journal.pone.0252182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/11/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use. MATERIALS AND METHODS The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index. RESULTS The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health. CONCLUSIONS This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.
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Affiliation(s)
- Mamothena Carol Mothupi
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Jeroen De Man
- Department of Primary and Interdisciplinary Care, Centre for General Practice, University of Antwerp, Antwerp, Belgium
| | - Hanani Tabana
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Lucia Knight
- School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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