Evaluating equity across the continuum of care for maternal health services: analysis of national health surveys from 25 sub-Saharan African countries

BACKGROUND: Ensuring access to the continuum of care for maternal, neonatal, and child health is an effective strategy for reducing maternal and child mortality. We investigated the extent of dropout, wealth-related inequalities, and drivers of inequality in the continuum of care for maternal health services in sub-Saharan Africa. METHODS: We analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 across 25 sub-Saharan African countries. We defined the continuum of care for maternal health services as women who had received at least four ANC contacts (ANC 4 + contacts), skilled care at birth, and immediate postnatal care (PNC). We used concentration index to estimate wealth-related inequalities across the continuum of care. Multilevel logistic regression models were used to identify predictors of inequality in completing the continuum of care. RESULTS: We included data on 196,717 women with the most recent live birth. About 87% of women reported having at least one ANC contact, but only 30% of women received the recommended care package that includes ANC 4 + contacts, skilled care at birth, and PNC. The proportion of women who had completed the continuum of care ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women reported not having contact with the health system during pregnancy or childbirth; this ranged from 0.1% in Burundi to 34% in Chad. Disadvantaged women were more likely to have no contact with health systems and less likely to have the recommended care package than women from wealthier households. Women with higher education levels, higher exposure to mass media (radio and TV), and higher household wealth status had higher odds of completing the continuum of care. CONCLUSIONS: Persistent and increasing inequalities were observed along the continuum of care from pregnancy to the postnatal period, with socioeconomically disadvantaged women more likely to drop out of care. Improving access to and integration of services is required to improve maternal health. Initiatives and efforts to improve maternal health should prioritise and address the needs of communities and groups with low coverage of maternal health services.