Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries.

Background: Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). Methods: Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. Findings: The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries. Interpretation: Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries. Funding: None.