Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Child immunization status according to number of siblings and birth order in 85 low- and middle-income countries: a cross-sectional study.

Background: Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods: We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010-2020) with information on immunisation status of children aged 12-35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings: We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12-35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation: The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding: Gavi, the Vaccine Alliance.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

Objective: To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods: We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings: In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion: The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Coverage, Trends, and Inequalities of Maternal, Newborn, and Child Health Indicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries.

Rapid urbanization is likely to be associated with suboptimal access to essential health services. This is especially true in cities from sub-Saharan Africa (SSA), where urbanization is outpacing improvements in infrastructure. We assessed the current situation in regard to several markers of maternal, newborn, and child health, including indicators of coverage of health interventions (demand for family planning satisfied with modern methods, at least four antenatal care visits (ANC4+), institutional birth, and three doses of DPT vaccine[diphtheria, pertussis and tetanus]) and health status (stunting in children under 5 years, neonatal and under-5 mortality rates) among the poor and non-poor in the most populous cities from 38 SSA countries. We analyzed 136 population-based surveys (year range 2000-2019), contrasting the poorest 40% of households (referred to as poor) with the richest 60% (non-poor). Coverage in the most recent survey was higher for the city non-poor compared to the poor for all interventions in virtually all cities, with the largest median gap observed for ANC4+ (13.5 percentage points higher for the non-poor). Stunting, neonatal, and under-5 mortality rates were higher among the poor (7.6 percentage points, 21.2 and 10.3 deaths per 1000 live births, respectively). The gaps in coverage between the two groups were reducing, except for ANC4, with similar median average annual rate of change in both groups. Similar rates of change were also observed for stunting and the mortality indicators. Continuation of these positive trends is needed to eliminate inequalities in essential health services and child survival in SSA cities.

Geographic inequalities in health intervention coverage - mapping the composite coverage index in Peru using geospatial modelling.

BACKGROUND: The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. METHODS: We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. RESULTS: CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. CONCLUSIONS: Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness.

Exploring the potential for a new measure of socioeconomic deprivation status to monitor health inequality.

BACKGROUND: Monitoring health inequalities is an important task for health research and policy, to uncover who is being left behind - and where - and to inform effective and equitable policies and programmes to tackle existing inequities. The choice of which measure to use to monitor and analyse health inequalities is thereby not trivial. This article explores a new measure of socioeconomic deprivation status (SDS) to monitor health inequalities. METHODS: The SDS measure was constructed using the Alkire-Foster method. It includes eight indicators across two equally weighted dimensions (education and living standards) and specifies a four-level gradient of socioeconomic deprivation at the household-level. We conducted four exercises to examine the value-added of the proposed SDS measure, using Demographic and Health Surveys data. First, we examined the discriminatory power of the new measure when applied to outcomes in four select reproductive, maternal, neonatal, and child health (RMNCH) indicators across six countries: skilled birth attendance, stunting, U5MR, and DTP3 immunisation. Then, we analysed the behaviour and association of the new SDS measure vis-à-vis the DHS Wealth Index, including chi-squared test and Pearson correlation coefficient. Third, we analysed the robustness of the SDS measure results to changes in its structure, using pairwise comparisons and Kendal Tau-b rank correlation. Finally, we illustrated some of the advantageous properties of the new measure, disaggregation and decomposition, on Haitian data. RESULTS: 1) Higher levels of socioeconomic deprivation are generally consistently associated with lower levels of achievements in the RMNCH indicators across countries. 2) 87% of all pairwise rank comparisons across a range of SDS measure structures were robust. 3) SDS and DHS Wealth Index are associated, but with considerable cross-country variation, highlighting their complementarity. 4) Haitian households in rural areas experienced, on average, more severe socioeconomic deprivation as well as lower levels of RMNCH achievement than urban households. CONCLUSIONS: The proposed SDS measure adds analytical possibilities to the health inequality monitoring literature, in line with ethically and conceptually well-founded notions of absolute, multidimensional disadvantage. In addition, it allows for breakdown by its dimensions and components, which may facilitate nuanced analyses of health inequality, its correlates, and determinants.

Modern contraceptive use among women in need of family planning in India: an analysis of the inequalities related to the mix of methods used.

OBJECTIVE: To evaluate the type of contraceptives used by women in need of family planning in India and the inequalities associated with that use according to women's age, education, wealth, subnational region of residence and empowerment level. METHODS: Using data from the Indian National Family and Health Survey-4 (2015-2016), we evaluated the proportion of partnered women aged 15-49 years with demand for family planning satisfied (DFPS) with modern contraceptive methods. We also explored the share of each type of contraception [short- (e.g., condom, pill) and long-acting (i.e., IUD) reversible contraceptives and permanent methods] and related inequalities. RESULTS: The majority (71.8%; 95% CI 71.4-72.2) of women in need of contraception were using a modern method, most (76.1%) in the form of female sterilization. Condom and contraceptive pill were the second and third most frequently used methods (11.8% and 8.5%, respectively); only 3.2% reported IUD. There was a nearly linear exchange from short-acting to permanent contraceptive methods as women aged. Women in the poorest wealth quintile had DFPS with modern methods at least 10 percentage points lower than other women. We observed wide geographic variation in DFPS with modern contraceptives, ranging from 23.6% (95% CI 22.1-25.2) in Manipur to 93.6% (95% CI 92.8-94.3) in Andhra Pradesh. Women with more accepting attitudes towards domestic violence and lower levels of social independence had higher DFPS with modern methods but also had higher reliance on permanent methods. Among sterilized women, 43.2% (95% CI 42.7-43.7) were sterilized before age 25, 61.5% (95% CI 61.0-62.1) received monetary compensation for sterilization, and 20.8% (95% CI 20.3-21.3) were not informed that sterilization prevented future pregnancies. CONCLUSION: Indian family planning policy should prioritize women-centered care, making reversible contraceptive methods widely available and promoted.

Ensuring universal access to sexual and reproductive health and reproductive rights for all women is one of the Sustainable Development Goals, promoted by the United Nations and adopted by 193 countries, including India. To address women's need for contraception, the provision of a wide range of safe, effective and affordable contraceptive methods is essential. In this study, we evaluated the type of contraceptives used by women in need of contraception in India and the inequalities in contraceptive use among different subgroups of women. The majority (71.8%) of women in need of contraception were using a modern method, most (76.1%) in the form of female sterilization. Condom and contraceptive pill were the second and third most frequently used methods (11.8% and 8.5%, respectively); only 3.2% reported IUD. We observed an exchange from short-acting to permanent contraceptive methods as women aged. The poorest women presented demand for family planning satisfied (DFPS) with modern methods at least 10 percentage points lower than other women. There was wide geographic variation in DFPS with modern contraceptives, ranging from 23.6% in Manipur to 93.6% in Andhra Pradesh. Women with more accepting attitudes towards domestic violence and lower levels of social independence had higher DFPS with modern methods but also had higher reliance on permanent methods. Among sterilized women, 43.2% were sterilized before age 25, 61.5% received monetary compensation for sterilization, and 20.8% were not informed that sterilization prevented future pregnancies. Indian family planning policy should prioritize women-centered care, making reversible contraceptive methods widely available and promoted.

Geospatial estimation of reproductive, maternal, newborn and child health indicators: a systematic review of methodological aspects of studies based on household surveys.

BACKGROUND: Geospatial approaches are increasingly used to produce fine spatial scale estimates of reproductive, maternal, newborn and child health (RMNCH) indicators in low- and middle-income countries (LMICs). This study aims to describe important methodological aspects and specificities of geospatial approaches applied to RMNCH coverage and impact outcomes and enable non-specialist readers to critically evaluate and interpret these studies. METHODS: Two independent searches were carried out using Medline, Web of Science, Scopus, SCIELO and LILACS electronic databases. Studies based on survey data using geospatial approaches on RMNCH in LMICs were considered eligible. Studies whose outcomes were not measures of occurrence were excluded. RESULTS: We identified 82 studies focused on over 30 different RMNCH outcomes. Bayesian hierarchical models were the predominant modeling approach found in 62 studies. 5 × 5 km estimates were the most common resolution and the main source of information was Demographic and Health Surveys. Model validation was under reported, with the out-of-sample method being reported in only 56% of the studies and 13% of the studies did not present a single validation metric. Uncertainty assessment and reporting lacked standardization, and more than a quarter of the studies failed to report any uncertainty measure. CONCLUSIONS: The field of geospatial estimation focused on RMNCH outcomes is clearly expanding. However, despite the adoption of a standardized conceptual modeling framework for generating finer spatial scale estimates, methodological aspects such as model validation and uncertainty demand further attention as they are both essential in assisting the reader to evaluate the estimates that are being presented.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Early childhood suspected developmental delay in 63 low- and middle-income countries: Large within- and between-country inequalities documented using national health surveys.

2Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil. BACKGROUND: The Sustainable Development Goals call for inclusive, equitable and quality learning opportunities for all. This is especially important for children, to ensure they all develop to their full potential. We studied the prevalence and inequalities of suspected delay in child development in 63 low- and middle-income countries. METHODS: We used the early child development module from national health surveys, which covers four developmental domains (physical, social-emotional, learning, literacy-numeracy) and provides a combined indicator (early child development index, ECDI) of whether children are on track. We calculated the age-adjusted prevalence of suspected delay at the country level and stratifying by wealth, urban/rural residence, sex of the child and maternal education. We also calculated measures of absolute and relative inequality. RESULTS: We studied 330 613 children from 63 countries. Prevalence of suspected delay for the ECDI ranged from 3% in Barbados to 67% in Chad. For all countries together, 25% of the children were suspected of developmental delay. At regional level, prevalence of delay ranged from 10% in Europe and Central Asia to 42% in West and Central Africa. The literacy-numeracy domain was by far the most challenging, with the highest proportions of delay. We observed very large inequalities, and most markedly for the literacy-numeracy domain. CONCLUSIONS: To date, our study presents the most comprehensive analysis of child development using an instrument especially developed for national health surveys. With a quarter of the children globally suspected of developmental delay, we face an immense challenge. The multifactorial aspect of early child development and the large gaps we found only add to the challenge of not leaving these children behind.

Trends in socioeconomic inequalities in stunting prevalence in Latin America and the Caribbean countries: differences between quintiles and deciles.

BACKGROUND: With the adoption of the Sustainable Development Goals (SDGs), there is a renewed commitment of tackling the varied challenges of undernutrition, particularly stunting (SDG 2.2). Health equity is also a priority in the SDG agenda and there is an urgent need for disaggregated analyses to identify disadvantaged subgroups. We compared time trends in socioeconomic inequalities obtained through stratification by wealth quintiles and deciles for stunting prevalence. METHODS: We used 37 representative Demographic and Health Surveys and Multiple Indicator Cluster surveys from nine Latin American and Caribbean (LAC) countries conducted between 1996 and 2016. Stunting in children under-5 years was assessed according to the 2006 WHO Child Growth Standards and stratified by wealth quintiles and deciles. Within-country socioeconomic inequalities were measured through concentration index (CIX) and slope index of inequality (SII). We used variance-weighted least squares regression to estimate annual changes. RESULTS: Eight out of nine countries showed a statistical evidence of reduction in stunting prevalence over time. Differences between extreme deciles were larger than between quintiles in most of countries and at every point in time. However, when using summary measures of inequality, there were no differences in the estimates of SII with the use of deciles and quintiles. In absolute terms, there was a reduction in socioeconomic inequalities in Peru, Honduras, Dominican Republic, Belize, Suriname and Colombia. In relative terms, there was an increase in socioeconomic inequalities in Peru, Bolivia, Haiti, Honduras and Guatemala. CONCLUSIONS: LAC countries have made substantial progress in terms of reducing stunting,. Nevertheless, renewed actions are needed to improve equity. Particularly in those countries were absolute and relative inequalities did not change over time such Bolivia and Guatemala. Finer breakdowns in wealth distribution are expected to elucidate more differences between subgroups; however, this approach is relevant to cast light on those subgroups that are still lagging behind within populations and inform equity-oriented health programs and practices.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.

BACKGROUND: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. METHODS: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. FINDINGS: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. INTERPRETATION: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. FUNDING: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.