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

Abstract

BackgroundSub-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.MethodsHere, 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.ResultsAcross 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.ConclusionsWe 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.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-6241-8) contains supplementary material, which is available to authorized users.

Does knowledge of danger signs influence use of maternal health services among rural women? Findings from Babati Rural district, Northern Tanzania.

“…Improvement in ANC 4+ times and SBA use has also been noted in other East African countries i.e. Uganda, Kenya and Rwanda [30]. Key question to follow will be if this improvement in use of health facilities is matched by improvement in quality of services offered to improve morbidity and mortality outcomes.…”

Modelling the Wealth Index of Demographic and Health Surveys within Cities Using Very High-Resolution Remotely Sensed Information

“…In most Sub-Saharan African (SSA) cities, census data is hard to access or outdated. For regional or national assessments a lot of survey indicators have been produced at coarser resolutions [6,[43][44][45][46][47][48][49][50][51] but this was the first DHS fine-scale indicator production derived from VHR earth observation information directed specifically for intra-urban policy making and decision support. An additional highlight of this work is that not only were VHR variables able to train robust models based on DHS surveys, but also their predictions were in relative agreement with exhaustive census data at various geographical resolutions.…”

Estimating uncertainty in geospatial modelling at multiple spatial resolutions: the pattern of delivery via caesarean section in Tanzania

“…With recent advancements in the collection and distribution of geo-located household surveys, such as those collected via the Demographic and Health Survey (DHS) programme (www.dhsprogram.com), researchers are increasingly using methods such as small area estimation and geostatistical additive models (GAMs) to generate high spatial resolution maps of health and development indicators 2–4. Such subnational, high-resolution estimates have become useful tools for researchers and policy makers alike in uncovering hidden health inequities that would otherwise be masked by aggregate or national-level health indicators, enabling targeted interventions in settings with limited resources 1 5–8…”

“…As with maternal mortality, data on life-saving MNH interventions such as antenatal care, skilled birth attendance and delivery via caesarean section (c-section) can be widely obtained at aggregate levels but remain difficult to measure at subnational levels, especially in the most rural and vulnerable areas of the world. While some work has been done modelling key MNH interventions at subnational scales such as maternal health services, exclusive breastfeeding, childhood vaccinations and health systems performances,5 6 13–15 other vital life-saving interventions that occur less frequently, such as delivery via c-section, have not been modelled previously at high spatial resolutions.…”