LAUSR

Background Improved access to and quality obstetric care in health facilities reduces maternal and neonatal morbidity and mortality. We examined spatial patterns, within-country wealth-related inequalities and predictors of inequality in skilled birth attendance and caesarean deliveries in sub-Saharan Africa. Methods We analysed the most recent Demographic and Health Survey data from 25 sub-Saharan African countries. We used the concentration index to measure within-country wealth-related inequality in skilled birth attendance and caesarean section. We fitted a multilevel Poisson regression model to identify predictors of inequality in having skilled attendant at birth and caesarean section. Results The rate of skilled birth attendance ranged from 24.3% in Chad to 96.7% in South Africa. The overall coverage of caesarean delivery was 5.4% (95% CI 5.2% to 5.6%), ranging from 1.4% in Chad to 24.2% in South Africa. The overall wealth-related absolute inequality in having a skilled attendant at birth was extremely high, with a difference of 46.2 percentage points between the poorest quintile (44.4%) and the richest quintile (90.6%). In 10 out of 25 countries, the caesarean section rate was less than 1% among the poorest quintile, but the rate was more than 15% among the richest quintile in nine countries. Four or more antenatal care contacts, improved maternal education, higher household wealth status and frequently listening to the radio increased the rates of having skilled attendant at birth and caesarean section. Women who reside in rural areas and those who have to travel long distances to access health facilities were less likely to have skilled attendant at birth or caesarean section. Conclusions There were significant within-country wealth-related inequalities in having skilled attendant at birth and caesarean delivery. Efforts to improve access to birth at the facility should begin in areas with low coverage and directly consider the needs and experiences of vulnerable populations.