Inequalities in Maternal Health Care Utilization in Sub-Saharan African Countries: A Multiyear and Multi-Country Analysis

Abstract

To assess social inequalities in the use of antenatal care (ANC), facility based delivery

(FBD), and modern contraception (MC) in two contrasting groups of countries in sub- Saharan Africa divided based on their progress towards maternal mortality reduction. Six

countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three

(Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average an- nual reduction rate. All of these countries had at least three rounds of Demographic and

Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as rel- ative and absolute concentration indices in order to examine within-country geographical

and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries

which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use in- creased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by

4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators

remained stagnant or increased. Absolute measures for geographical and wealth-based in- equalities remained high invariably in all six countries. The increasing trend in the utilization

of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.