Disability status and socioeconomic related inequality in receiving quality antenatal care in nine low- and middle-income countries: A multilevel analysis.

Abstract

Background: Quality of antenatal care (ANC) is a cornerstone to achieving progress in maternal and child health. ANC quality has not been fully explored among women with disability (WwD). We assess socioeconomic inequalities in utilization of quality ANC among reproductive aged women with and without disability.

Methods: This study utilized Demographic and Health Survey (DHS), which is population-based survey conducted nine low-and middle-income countries (LMICs): Mauritania (2019-21), Rwanda (2019-20), South Africa (2016), Mali (2018), Senegal (2019), and Uganda (2016), Cambodia (2021-22), Pakistan (2017-18), and Timor-Leste (2016). Disability status was measured by the Washington Group Short Set questionnaires (WG-SS) and quality of ANC was measured by a validated tool (ANCq), constructed from seven aspects of quality ANC: number of ANC, timely initiation, blood pressure measurement, blood and urine samples taken, and minimum of two doses of tetanus toxoid immunization. Wealth-related inequality in utilization of quality ANC was measured by concentration indices. Mixed-effects logistic regression fitted, and result presented in Adjusted odds ratio (AOR) with 95% confidence interval (CI).

Results: One in seven women (14.0%) had at least some difficulty in at least one domain of function. While most participants (90.3%) had at least one ANC visit, high-quality ANC was received by only 42.6% with 38.8% among WwD. Five out of seven aspects of ANCq were lower among WwD compared to WwoD. The overall receipt of high-quality ANC is pro-rich (CCI 0.27, 95% CI: 0.26-0.29), however the inequality among WwD and WwoD differs across countries. Coverage of high-quality antenatal care varied between countries, from 78.5% in Cambodia to 30.9% in Mali. The odds of receiving high-quality ANC were lower among WwD (AOR = 0.88, 95% CI: 0.83-0.94), higher for wealthier households (AOR = 2.16: 95% CI: 1.94-2.41) richest compared to poorest quintile) and lower for women facing significant barriers to healthcare (AOR = 0.76, 95% CI: 0.72-0.80).

Conclusions: Despite high initial ANC visit, a significant portion of women, particularly WwD, received lower quality ANC than recommended. These findings highlight the disadvantages faced by WwD, who have fewer ANC visits and substandard care when services are available. Regional disparities demonstrate the need for region-specific strategies. Reducing barriers to healthcare access, particularly for disadvantaged populations, are crucial steps towards achieving equitable maternal health outcomes across LMICs and achievement of SDG3.1 by 2030.