Effective coverage for reproductive, maternal, neonatal and newborn health: an analysis of geographical and socioeconomic inequalities in 39 low- and middle-income countries

RMNCH effective coverage in 39 LMICs by HDI

Figure 1 illustrates the RMNCH coverage in 39 LMICs, stratified by HDI. The results show that in family planning care, 60.8% of the targeted population had service contact coverage, while 31.4% and 12.1% had crude and quality-adjusted coverage, respectively. For ANC, 82% of the targeted population reached service contact coverage, while 53.4%, 37.7% and 24.2% reached crude, quality-adjusted and user-adherence coverage, respectively. In childbirth care, 74.6% reached service contact coverage, and 70.9% reached crude coverage. For PNC, 79.0% of the targeted population reached service contact coverage, while 35.3% and 13.8% reached crude and quality-adjusted coverage, respectively. Notably, countries with higher HDI had better effective coverage in the quality of care for RMNCH than countries with lower HDI, across all RMNCH service care continuums.

We also found that the urban area has a higher quality of care than the rural area, especially for ANC, childbirth and PNC (see online supplemental figure S1 (RMNCH coverage by rural and urban areas across 39 LMICs). For example, 85% (95% CI=85–86%) of women in the urban area received SBA at a health facility (crude coverage), compared with 64% (95% CI=64–65%) in the rural area. Around 91% (95% CI=90–91%) of newborns in the urban area received PNC from a skilled provider (service contact), compared with 74% (95% CI=73–74%) in the rural area.

The rural–urban disparities show the rural–urban difference in family planning was small in all HDI groups (figure 2). On the other hand, low-HDI countries had a higher urban–rural gap for ANC, childbirth and PNC services (figures 2 and 3), while high-HDI countries had statistically insignificant differences of urban–rural coverages across all outcomes. Delving more specifically into each country’s gaps, we found that the greatest rural–urban gaps were mostly found in low-HDI countries. The largest urban–rural gap in service contact coverages was found in Angola for family planning (28.7 pp, 95% CI=24.4–33.1); and Ethiopia for ANC (31.8 pp, 95% CI=25.7–38.0), childbirth (60.4 pp, 95% CI=53.5–67.4) and PNC services (58.5 pp, 95% CI=51.6–65.4). For crude/quality-adjusted coverage, the greatest rural–urban gaps were found in Senegal (19.5 pp, 95% CI=16.6–22.4) for family planning; Myanmar for ANC (46.4 pp, 95% CI=40.4–52.4); Ethiopia for childbirth care (61.7 pp, 95% CI=54.8–68.6); and Zambia for PNC services (21.3 pp, 95% CI=17.5–25.1). The rural–urban gaps in childhood mortality rates (figure 4) were markedly large in Guinea, Cambodia, Afghanistan and Nigeria. For example, the IMR in Guinea was 76.7 per 1000 live births in rural areas, compared with 38.4 per 1000 live births in urban areas—a gap of 38.3 deaths per 1000 live births. Online supplemental figure S1 provides the pooled estimates of the mortality rates in 39 countries, by urban–rural disaggregation.

Socioeconomic inequalities in RMNCH effective coverage in rural and urban areas

Table 1 displays the inequalities in RMNCH service in both urban and rural areas, by HDI categories. The measurement for socioeconomic inequalities RII index was significant in both rural and urban areas, suggesting large disparities in effective coverage across socioeconomic groups in LMICs. Our results suggested that in most indicators, socioeconomic inequalities were more pronounced in rural areas compared with urban areas. For example, in medium-HDI countries, the RII for ANC user-adherence coverage in urban areas was 1.9 (95% CI=1.8–2.1), whereas RII was 3.6 (95% CI=3.4–3.8) in rural areas. See also online supplemental tables S5 and S6 for inequality calculation by the crude coverage level and socioeconomic status, respectively.

Our results also revealed that socioeconomic inequalities in RMNCH were more significant in the quality-adjusted indicators that are more difficult to attain than the service contact indicators (online supplemental figure S3). For instance, using the service contact measurement, the RII differences for ANC visits were close to zero, but when based on quality-adjusted coverage, the RII differences were noticeably increased in nearly all countries, particularly in Bangladesh (RII dif=9.7 pp) and Guinea (RII dif=3.5), showing in the upper-left quadrant.