Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya
Authors: Emily Catherine Keats, Nadia Akseer, Zaid Bhatti, William Macharia, Anthony Ngugi, Arjumand Rizvi, Zulfiqar Ahmed Bhutta
Journal: JAMA Network Open (2018)

<h3>Importance</h3> Previous work has underscored subnational inequalities that could impede additional health gains in Kenya. <h3>Objective</h3> To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014. <h3>Design, Setting, and Participants</h3> This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018. <h3>Exposures</h3> Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered. <h3>Main Outcomes and Measures</h3> Absolute and relative measures of inequality in coverage of RMNCAH interventions. <h3>Results</h3> For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of −7.9% (95% CI, −11.1% to −4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations. <h3>Conclusions and Relevance</h3> Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.