Mortality around childbirth, including mothers, their unborn foetuses (stillbirths) and newborns, is essentially a disease of poverty. There are wide inequalities between nations, with greatest mortality in low and middle income countries. Regarding maternal mortality, all metrics indicate wide disparities (1): the largest gap is seen in the lifetime risk of dying during childbirth, which ranges from 1 in 41 in low-income, to 1 in 3300 in high-income countries (HIC). The burden of maternal deaths is greatest in Sub-Saharan Africa (SSA), which accounted for 64% of global deaths in 2015 (2). There are gaps in newborn survival and stillbirths. Newborns in SSA are nine times more likely to die than those in HIC (3). The highest stillbirth rates and numbers are concentrated in SSA and South-East Asia (4). In SSA alone, over 201 000 maternal deaths, 1 027 000 newborn deaths and 1 060 000 stillbirths were estimated in 2015 (4). Gradients in mortality have been documented within low income countries, with the poorest disproportionately affected (5, 6). The figure shows maternal mortality by wealth quintiles in selected countries (5). An inverse relationship between poverty and maternal health has been known for over a century, supported by data from high income countries (5, 7). Present day inequalities within countries have been extensively described (8), and are often masked by national averages (9). In SSA, in the past rural contexts generally fare worse than urban ones (5), though this may be changing. Gaps in uptake of key interventions between the rich and the poor are likely to explain at least part of the differences, though it is unlikely to be the only explanation. Skilled birth attendance (SBA) was considered the key intervention in the Millennium Development Goals era (11, 12). Policies to improve SBA have increased health facility deliveries throughout low income countries (10); despite rising coverage, rich-poor inequalities in access to this service persist in all countries and contexts (6). Socio-economic inequalities in cesarean sections, a life-saving procedure for mothers and their foetuses, have been documented throughout SSA countries (14). In a review of interventions, there was greater inequality in facility-based ones than in community-based interventions (13). Building up effective primary health care (PHC) systems to respond to women’s and families’ need has been at the centre of most health system strategies in SSA. Tanzania, for example, developed a dense primary care facility network following policy expressed in the Arusha Declaration (1967), to bring preventive and curative services to its mostly rural population, not fully served by a health system based on hospitals (15). Presently, it is estimated that 85% of a population of 54 300 000 (2015) live within an hour's walk from a facility (16). In Rwanda, health infrastructure was largely destroyed and health staff were killed during the 1994 genocide. Yet, following reconstruction efforts with a focus on primary health care, it is one among few countries to have achieved universal health coverage (17). It is estimated that 85% of the population lives within 90 min of a facility (18). Rural health systems’ expansion, striving to make services geographically accessible, may have been at the expense of obstetric services’ quality (19, 20). Despite increasing proportions of deliveries in facilities throughout SSA (10), expected mortality reduction has not been observed (1). In pyramidal-shaped health systems, childbirth care is available from the primary care or first-line level of the health system, with advanced management of childbirth complications (including cesarean sections and blood transfusions) only available from hospital level (1). Evidence mainly from Tanzania indicates existence of a multi-tiered health system, with the first-line providing more limited quality. The most compelling evidence comes from a study on determinants of maternal mortality in Southern Tanzania: maternal mortality reduced with proximity to hospitals, but lower distance to other health facilities had no effect (21). The weakness of the peripheral health system in Tanzania has been documented (22-25). The focus for improving outcomes for mothers and their babies is increasingly on quality of care (10). A recent review on quality of health systems in low income countries (26) hypothesised that childbirth care should only be available in hospitals. Urbanisation in SSA adds new challenges to obstetric services. Though SSA remains mostly rural, the urban component is increasing rapidly. In 2014, 37% of population was urban, but it is expected that by 2025 the majority will be urban (55%) (27). Rising poverty and lack of infrastructure negatively impact the health of mothers and their babies. Evidence from Tanzania indicates the existence of an urban-rural gap in the country (28). Life expectancy is now greater for rural inhabitants than for urban dwellers. Census data (2012) (29) found a significant difference in maternal mortality for urban women compared to their rural counterparts (432 versus 336 deaths per 100,000 live births). Fundamental differences in the dimensions of poverty in rural and urban contexts (30), in geographical accessibility, in population and facility densities, underline the need to analyse the two contexts separately. Against this background, the study plans to explore the effect of socio-economic status on access to a multi-tiered health system for delivery care in sub-Saharan Africa. Understanding whether access to childbirth care in hospitals is equitable is essential to formulate strategies to improve care and outcomes for poorer mothers and their babies, and ultimately for their whole communities. Available evidence suggests socio-economic factors influence women’s access to childbirth services. When facility delivery coverage is low, poorer women tend to deliver at home. Multi-country analysis of Demographic and Health Survey (DHS) data collected between 2003-2009 found that in sub-Saharan Africa >70% of women from the two lowest socio-economic quintiles had delivered at home, compared to only 22.4% from the highest quintile (31).
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