Social and geographical inequalities in prenatal care coverage in Colombia: a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Abstract

Background: Access to adequate antenatal care (ANC) is crucial for improving maternal and neonatal health outcomes. Despite high national ANC coverage, Colombia still faces regional and socioeconomic disparities. This study aims to estimate geographical and intersectional inequalities in ANC coverage and evaluate the contribution of social determinants to these disparities.

Methods: We conducted a cross-sectional observational study using data from live birth certificates of singleton pregnancies in Colombia during 2022. Multilevel analysis of individual heterogeneity and discriminatory accuracy was performed using logistic regression models. Two approaches were applied: (1) geographical, with departments as the second level and (2) intersectional, with strata as the second level, defined by the combination of health insurance, area of residency, ethnicity and maternal age. The variance partition coefficients (VPCs) from the random-intercept versions of the models were used as the disparity measure. Random slopes were included to allow for variations in the effects of ethnicity and insurance across departments.

Results: A total of 552 284 singleton pregnancies were analysed. National ANC coverage was 95.96%. However, 15 of the 33 departments and 24 of the 36 intersectional strata reported ANC coverage below the national average. For the geographical analysis, the VPC dropped from 24.45% to 10.02%, after accounting for population compositional effects. For the intersectional analysis, the VPC dropped from 39.43% to 3.64%, after adjusting for the additive effects of the individual characteristics used to define the strata. Ethnicity and health insurance were the most significant determinants of both geographical and intersectional heterogeneity. The effect of both factors varied significantly across departments.

Conclusions: Colombia faces significant geographical and intersectional inequalities, primarily driven by inequities in ethnicity and health insurance coverage. Policies targeting these social determinants are needed to ensure equitable access to maternal health services.