Addressing Inequalities in Access to Quality Maternal and Child Health Services in Sub-Saharan Africa

A smiling woman holds a smiling baby up at head height.

Authors – Firew Bobo (PhD Candidate, University of Technology Sydney, UTS); Professor Andrew Hayen, (UTS); Professor Angela Dawson; (UTS)

How long people live dramatically varies depending on socioeconomic status, education levels, place of birth, and country of residence. Higher levels of illness and premature mortality are more common among the poorest of the poor. Health and illness follow social status: the lower the socioeconomic position, the worse the health.

According to the World Health Organization, health is human right, which affirms and envisions “…the highest attainable standard of health as a fundamental right of every human being.” Therefore, systematic differences in health are unfair, unreasonable, and must be avoided.

In 2015, more than 800 women died every day from complications related to pregnancy and childbirth. Almost all (99%) of these deaths occurred in developing countries and most (66%) were from sub-Saharan Africa. In low-income and middle-income countries, encouraging progress has been made towards increasing access to health services. However, the quality of care across countries and health status remains low, and impedes progress to improving health outcomes.

Globally recognised evidence-based health care interventions can largely prevent the death of women from pregnancy-related causes. Antenatal care (ANC) attendance, facility-based delivery and a skilled health worker at delivery improves maternal health. Nevertheless, the use of these interventions is limited in developing countries including the SSA region. We analysed inequalities in access to quality maternal and child health services in SSA using Demographic and Health Survey Data based on a set of tracer indicators that provide a comprehensive picture of maternal and child health services coverage in SSA.

Access to maternal health services in sub-Saharan Africa

In our first paper, published in Health Policy and Planning, we examined inequalities in the quality of antenatal care in nine east African countries. The findings highlight a large gap between the contact and content of the antenatal care women received. Our analysis also revealed low-quality antenatal care across all countries. Women who received quality antenatal care were largely educated, lived in urban areas, and planned to have a child. Overall, 94.8% of women had one or more ANC contacts, but only 31.1% of women had a first contact before 12 weeks of gestation. More than half of women (54.4%) had four or more ANC contacts, but only 21% of women received quality ANC.

We then looked at special patterns and inequalities in skilled birth attendance and caesarean section in sub-Saharan Africa in our second paper published in BMJ Global Health. The coverage of skilled birth attendance ranged from 24.3% in Chad to 96.7% in South Africa. Our findings showed significant pro-rich inequalities in skilled birth attendance and caesarean section across all 25 SSA countries. In most countries, the coverage of caesarean section was extremely low, particularly among the poorer populations. In 10 out of 25 countries, the caesarean section rate was less than 1% among the poorest quintile, but the rate was more than 15% among the richest quintile in nine countries. Those women who had skilled birth attendance and caesarean delivery were more educated, had access to mass media (TV), had four or more ANC contacts, were residents of an urban area, and had no distance problems to access a health facility.

Bridging the gap in access to maternal health services

Continued efforts are needed to reach disadvantaged women. We recommend several strategies to address these gaps.

  • Implementing effective coverage as a primary strategy to bridge the quality gap in antenatal care services. Effective coverage requires that performance is measured not only by the number of people the health system is able to reach, but also by incorporating indicators to monitor the content of care women receive.
  • Improving access for vulnerable rural women through funding for transport infrastructure and targeted subsidies for services.
  • Strong focus on quality improvements at all levels of health facilities, focusing on ensuring and achieving respectful, non-abusive, and high-quality maternity care for all women.
  • Primary initiation of quality improvement efforts in areas with poor access to maternal health and directly consider the needs and experiences of poor and vulnerable populations.

Child vaccination in sub-Saharan Africa

Our third paper assessed inequalities in child vaccination coverage in sub-Saharan Africa. Overall, 56.5% of children received full vaccination in 25 sub-Saharan African countries; this ranged from 24% in Guinea to 93% in Rwanda. The proportion of zero-dose vaccination was 8.4%; this ranged from 0.3% in Burundi to 23% in Guinea. We found strong pro-rich full vaccination coverage in the majority of the countries, except for Gambia and Namibia.  On the other hand, zero-dose children were disproportionately concentrated among disadvantaged subgroups in most countries.

Addressing vaccine inequity

Our research shows the need for the following actions:

  • Ensuring adequate vaccine supply; health facilities should address vaccine stocks by securing adequate vaccine doses and ensuring reliable cold chain management.
  • Addressing vaccine hesitancy; health service delivery systems should focus on increasing demand for vaccination services by providing targeted health information and education on the benefits and safety of vaccines.
  • Improved training of personnel is necessary to strengthen screening and delivery vaccines to all previously unvaccinated eligible children and improve health worker attitudes towards service users.
  • Targeted vaccination programs; vaccination services should primarily target areas with poor vaccination coverage and directly consider the needs and experiences of poor and vulnerable populations. In addition to education initiatives, areas with critical vaccination coverage gaps can be supported by monetary or material incentives.


Firew Bobo is a PhD candidate at the University of Technology Sydney; Andrew Hayen is Professor of Biostatistics and Deputy Head of the School of Public Health (Teaching and Learning), University of Technology Sydney; Angela Dawson is a Professor of Public Health and the Associate Dean Research of Faculty of Health, University of Technology Sydney.

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