Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999–2015

Abstract

Background

Sub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales.

Methods

Here, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country.

Results

Across all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services.

Conclusions

We found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.