Coverage of RMNCH interventions: more analysis is needed
Authors: Mamadou Dioulde Balde
Journal: The Lancet Global Health (2021)

In The Lancet Global Health, Daniel Leventhal and colleagues1Leventhal DGP Crochemore-Silva I Vidaletti LP Armenta-Paulino N Barros AJD Victora CG Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.Lancet Glob Health. 2021; 9: e1101-e1109Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar report their cross-sectional study of delivery channels and socioeconomic inequalities in the coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions in low-income and middle-income countries. The authors used secondary data from Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) from 36 low-income and middle-income countries to analyse 20 key indicators across four RMNCH distribution channels. These channels were: facility-based interventions, community-based interventions, environmental interventions, and so-called cultural interventions. The objective of this study was to measure the extent of inequality in the indicators studied, taking into account the distribution channels. The authors found that, of all the indicators, environmental indicators (cooking fuels, sanitation, running water) showed the greatest inequality of distribution or use in favour of wealthy women, children, and households. This observation is easily understood because the acquisition of these environmental indicators requires availability of resources related to the cost of housing and water and sanitation facilities. On the other hand, community-based interventions showed the lowest inequality in distribution or use across households because they are usually delivered by community health workers at little or no cost to families. Such interventions include immunisations, management of common diseases (such as malaria, diarrhoea, and pneumonia), and insecticide-treated bednets or household spraying.1Leventhal DGP Crochemore-Silva I Vidaletti LP Armenta-Paulino N Barros AJD Victora CG Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.Lancet Glob Health. 2021; 9: e1101-e1109Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar In this study, family planning services were included in the community-based interventions category; however, these services might be provided at the community level, in health facilities, or a combination of both depending on the country. Cultural indicators (in this study, exclusive breastfeeding until age 6 months and continued breastfeeding to age 12–15 months) showed inequality of uptake in favour of poor women, children, and households. The authors justify these behaviours as being culturally driven because they are not substantially affected by health services, and are instead determined by culture and economics (eg, affordability of formula milk and of clean water to prepare it).1Leventhal DGP Crochemore-Silva I Vidaletti LP Armenta-Paulino N Barros AJD Victora CG Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.Lancet Glob Health. 2021; 9: e1101-e1109Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar However, overall, the interventions in health facilities showed an absolute inequality in favour of distribution, access, or use by wealthy women, children, and households. These interventions included antenatal and postnatal care and institutional delivery. This observed inequity is due to geographical (distance from fixed facilities) and cultural barriers (such as women being unable to leave the house unaccompanied), and costs related to payment for services (in many countries) and transport. The results of this study show that the ways in which socioeconomic inequalities strongly contribute to uptake of these interventions, particularly when it comes to some delivery channels. In this respect, environmental indicators and interventions in health facilities are eloquent examples—for environmental interventions, people with sufficient economic resources have less difficulty in obtaining them than many other interventions, and for in health facility interventions inequality is more substantial among poor households and communities.2Ganle JK Parker M Fitzpatrick R Otupiri E A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition.BMC Pregnancy Childbirth. 2014; 14: 425Crossref PubMed Scopus (70) Google Scholar Finally, access to the benefits of RMNCH interventions reveals a clear gap between wealthy and poor women, children, and households.1Leventhal DGP Crochemore-Silva I Vidaletti LP Armenta-Paulino N Barros AJD Victora CG Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.Lancet Glob Health. 2021; 9: e1101-e1109Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar A factor that contributes to inequality in health facility-based interventions that is not included in the analyses in this Article is the mistreatment of women by health-care providers during antenatal care and facility-based childbirth (eg, shouting or slapping).3Bohren MA Mehrtash H Fawole B et al.How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys.Lancet. 2019; 394: 1750-1763Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar The absence of a childbirth companion contributes to increased rates of mistreatment of women during facility-based childbirth in low-income countries.4Balde MD Nasiri K Mehrtash H et al.Labour companionship and women's experiences of mistreatment during childbirth: results from a multi-country community-based survey.BMJ Glob Health. 2020; 5e003564Crossref PubMed Scopus (5) Google Scholar Variations in antenatal care have not been extensively discussed in the Article by Leventhal and colleagues; however, the success of childbirth is highly dependent on the success of the antenatal consultation. Analysis of inequalities in postnatal care (both for the mother and child) might also reflect these socioeconomic inequalities, had it been possible for the authors to examine this.5Ayele BGM Woldu MA Gebrehiwot HW et al.Magnitude and determinants for place of postnatal care utilization among mothers who delivered at home in Ethiopia: a multinomial analysis from the 2016 Ethiopian demographic health survey.Reprod Health. 2019; 16: 162Crossref PubMed Scopus (6) Google Scholar, 6Balde MD Diallo A Soumah AM et al.Barriers to utilization of postnatal care: a qualitative study in Guinea.Open J Obstet Gynecol. 2021; 11: 391-402Crossref Google Scholar Policy makers need to learn from community-based delivery channels to promote more equitable access to all RMNCH interventions. Thus, environmental interventions, especially the availability of water, could benefit from the support of community workers who are trained to promote the distribution of water, starting with the provision of water in public fountains or water tanks, particularly in rural areas. In summary, this is a very interesting study that highlights the importance of distributional channels for RMNCH interventions to achieve greater equity between wealthy and poor households. For future analyses, the inclusion of reproductive health among adolescents will be of great importance as part of Reproductive, Maternal, Newborn, Child and Adolescents Health (known as RMNCH+A) activities. I declare no competing interests. Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countriesInterventions that are often delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities or those that require changes in the home environment. Policy makers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. Full-Text PDF Open Access