We explored socioeconomic inequalities in ANC in 63 LMICs using the ANCq indicator. Important inequalities in ANCq across socioeconomic groups were observed between and within countries and world regions. Women in urban areas, with secondary or more education, belonging to wealthier households and higher empowerment had higher ANCq scores in nearly all countries.
Studies measuring inequalities in maternal health care across a large number of countries have also shown that use of maternal health care varied greatly both within and between countries, and factors such as wealth, location, woman’s education, religion, and decision-making power are associated with the presence of inequalities [1, 2, 9, 21]. A study that analyzed 12 maternal, newborn and child health interventions from 54 countries found that four or more ANC visits was the second most inequitable indicator (after skilled attendant at birth), with an overall coverage of 49.5% (95%CI:35.6–66.7), and a difference of 34.6 percent points between women in the poorest quintile and those in the wealthiest [2].
Several studies exploring the determinants on ANC consistently found that women living in urban areas, having higher levels of education, from the wealthiest households, and having higher empowerment levels are more likely to seek the recommended number of ANC visits, ensure early initiation or have good quality in ANC [4, 5, 22–24].
A study conducted in São Tomé and Príncipe explored factors associated with adequate ANC found that it was adequate in 26% of the sample and was associated with maternal education and wealth. Women with higher education and belonging to the wealthiest households had four (OR:4.01; 95%CI:1.59–10.09) and two times (OR:1.99; 95%CI:1.19–3.34) the odds of receiving adequate ANC compared to those with no education and women belonging to the poorest households, respectively [25].
Similar findings were reported by Fagbamigbe and Idemudia [3] in their study aimed to assess the quality of ANC services in Nigeria. Authors reported that less than 5% of ANC users received the desirable quality of ANC, and women with higher education (OR:2.69;95%CI:2.20–3.30), from wealthiest households (OR:3.54; 95%CI:2.65–4.72) had higher odds of receiving good quality in ANC; while women residing in rural areas (OR:0.83; 95%CI:0.74–0.94), and were not attended to by skilled ANC provider (OR:0.71; 95%CI:0.57–0.89) had lower odds.
Our findings are in line with the literature. Where our results advance the current knowledge is in the use of an indicator that includes information on quality and at the same time is applicable to all women in need of ANC. Our results show gaps that are not only related to having had contact with the services. When we find gaps wide as those presented by Angola and Pakistan, we see that the richest groups in those countries are on a par with the richest in the best performing countries, where women get a high number of visits and nearly all desired interventions. Furthermore, the poorest groups present scores that are among the worst, between 3 and 4 ANCq points. Women with 4 points in the ANCq score mostly had less than four ANC visits, tetanus immunization, a skilled provider, blood pressure measured, and nothing else [8].
In terms of absolute wealth inequalities, measured by the SII, we observed that countries with higher mean ANCq presented lower inequalities, generally. Most of them are upper-middle income countries. Also, we noted that countries with average ANCq scores had a wide range of inequality, with some of them achieving very low inequality, as Malawi or Rwanda. Nevertheless, some countries showed high inequalities despite having average ANCq scores, such as India (ANCq: 6.8; SII: 4.6) or Pakistan (ANCq: 6.5; SII: 5.5). Countries with these characteristics are mostly low and lower-middle income countries. Our results also allow us to identify countries with very low ANCq, or very high inequality, or both. That can be a wake-up call for multilateral agencies and countries to focus their attention on this key aspect of maternal care. At the same time, we highlight some positive examples that could be studied and followed, like Thailand, Maldives and Dominican Republic.
Our results also showed that while there was large variability across countries in terms of mean ANCq, countries from Latin America and the Caribbean presented higher ANCq scores and less variability between them. In the same vein, an analysis of socioeconomic differences in the quality of ANC services in 59 LMICs from six world regions reported that Latin America and Caribbean women received more ANC services compared to women in the other regions [21]. Additionally, a study conducted to analyze global inequality in maternal health care service utilization, mainly ANC and skilled birth assistance, showed that among the LMICs included, Latin America and Caribbean was the region with the highest prevalence of access to both care services, while Africa and Asia had the lowest prevalence and more disparities between countries [9], similar to our findings.
Monitoring health inequalities has become a priority in the Sustainable Development Goals (SDG) era helping countries to track progress towards the proposed goals and ensure that nobody is left behind [26]. Despite all efforts in ANC programs, inequalities in coverage and quality of ANC services persist. Our findings suggest that interventions, that consider the social determinants of health and reduce socioeconomic inequalities in ANC are required in most LMICs. Also, those gaps that we documented must be bridged to achieve maternal and child mortality goals proposed in the 2030 SDG agenda.
Inequality is multidimensional, and disaggregating data permits tracking the health issues among disadvantaged subgroups considering contextual factors and priorities on a practical level [27]. The information used in this paper is based on self-report, and it could be considered a limitation that should be noted, however all survey-based indicators used for SDG monitoring have the same problem [27]. LMICs often lack good health information systems for monitoring health inequalities, and nationally representative surveys are, in most cases, the best available data source [28].
Suitable approaches to monitoring ANC inequalities between and within countries are essential to provide evidence for practices, programs and policies aimed at reducing inequities [28], and to trace the impact of interventions. The ANCq is a new alternative, with several advantages, one of them being its ease of computation. It can be a valuable tool in this endeavor.