Inequities in maternal and child health outcomes and interventions in Ghana

In Africa, modest progress has been registered towards achieving MDGs 4 and 5. However, the rate of progress has been short of what is required to reach the targets. In sub-Saharan Africa, under-five mortality rate decreased from an average of 180 per 1,000 live births in 1990 to 129 per 1,000 live births in 2009 [6]. This translates to an average annual rate of reduction (AARR) of 1.7%, which is far below the AARR of 4.3% required to achieve the MDG 4 target of reducing by two-thirds, between 1990 and 2015, the mortality rate in under-five children. In sub-Saharan Africa, Madagascar, Eritrea and Cape Verde registered under-five mortality AARR of 4.3% or more between 1990 and 2009 [7], and are thus on track to achieve the MDG 4A target. The corresponding AARR for Ghana for the period 1990-2009 was 2.9% [7], and therefore the country is not on track to achieve MDG4A target. Progress in achieving the MDG 5 target of reducing the maternal mortality ratio (MMR) by three-quarters, between 1990 and 2015, has been slow. In sub-Saharan Africa, the maternal mortality ratio decreased from an average of 870 per 100,000 live births in 1990 to 640 per 100,000 in 2008 corresponding to an AARR of 1.7%, which is also far below the required 5.5% to achieve the MDG 5A target of maternal mortality reduction. Although many countries in the region are making progress to achieving the target, only two countries - Equatorial Guinea and Eritrea- are on track. Ghana's AARR in maternal mortality ratio during the same period was 3.3% [8].

Modern health interventions play a significant role in reducing childhood mortality in Africa and other developing countries [9]. There is ample evidence that MDG 4 can be achieved if countries in sub-Saharan Africa and other developing regions of the world target the biggest childhood killers in children - diarrhoea, malaria and pneumonia that account for more than half of under-five deaths. Scaling up of essential curative, preventive and promotive childhood interventions such as immunization, breast feeding, vitamin A supplementation and provision of safe drinking water are necessary to curb childhood morbidity and mortality [10]. Interventions such as focused antenatal care (four visits with a health care provider) and use of skilled attendants during child birth are cost-effective interventions to curb maternal morbidity and mortality.

Despite the modest progress observed, there are substantial inequities in maternal and child health services coverage and health outcomes within and between countries [11]. Current evidence indicates that poor people in both rich and poor countries bear a disproportionately higher burden of ill-health and death, but contrary to expectation have disproportionately less access to health services and interventions than those who are better off [6]. Evidence from various studies in sub-Saharan Africa attests to this [12].

Thus for practical reasons, it is important to examine the equity dimension of health outcomes and interventions in order to better target resources to those who have greater needs and achieve the national and global health targets. This paper, therefore, uses Ghana as case study to assess wealth-related inequalities in maternal and child health outcomes and interventions that are deemed as inequities. Following Whitehead's seminal definition, equity in health is the absence of systematic inequalities in health or in the major social determinants of health among people that have different positions in social hierarchy [13].

This study attempts to examine socio-economic inequalities in maternal and child health outcomes and interventions in Ghana using population weighted, regression-based measures of slope and relative index of inequality. Assessing these socio-economic inequalities, which in this case are referred to us inequities, is very important for evidence-based decision-making and targeting scarce public resources to those with more need. Achieving the relevant health-related MDG targets becomes difficult in the presence of inequities in health and health care that disadvantage the poor, since it is among the poorest groups that the MDG indicators are not good and there is a significant potential for improvement in these groups [2].

The selected maternal and child health outcomes indicate that a challenging task lies ahead to improve the health status of women and children in Ghana, although some of the indicators appear relatively better compared to average figures for countries in sub-Saharan Africa. The high rates of childhood mortality and malnutrition among children and women are of great concern if the country is to accelerate progress towards achieving the MDGs related to maternal and child health. Anaemia is a severe public health problem in Ghana, as it exceeds the 40% cut-off mark for the classification of public health significance of anaemia in populations [23].

The overall coverage levels of the selected maternal and child health interventions are still low with the exception of immunization coverage and Caesarean delivery. It should, however, be noted that these average figures mask the reality. For example, while the population average rate of Caesarean delivery is about 6.9%; disaggregation of the rate by wealth quintile shows that the rate among the wealthiest 20% is 14 times more than the rate among the poorest 20% (15% vs. 1.3%). Although there is a debate, a population-based Caesarean section rate of 5-15% has been considered as the acceptable level to ensure the best outcomes for mothers and children [24]. The proportion of deliveries by Caesarean section in a geographical area is a measure of access to and use of obstetric emergency care for averting maternal and neonatal deaths [19]. Therefore, there is under-provision of Caesarean section to the poorest segment of society, which poses a serious challenge to curbing maternal mortality. This impedes the achievement of MDG 5.

The slope and relative indices of inequality reveal the existence of statistically significant gradients in the following health outcome measures: stunting, underweight, anaemia and diarrhoea in under-five children; and, underweight/thin (BMI < 18.5), overweight (BMI = 25-29.9), obese (BMI ≥ 30) and anaemia in women in the age group 15-49 years. With the exception of overweight and obesity in women 15-49 age, all other indicators show a pro-wealthy inequity. This implies that the rates of these health outcome indicators decline significantly as one moves from the poorest wealth quintile to the wealthiest quintile. In contrast, the childhood mortality indicators - IMR, U5MR and perinatal mortality rate - and wasting in under-five children do not exhibit wealth related gradients that may be labeled as inequities.

The nutritional status of under-five children is one of the indicators of household well-being and determinants of child survival [25]. The world Health Organization recommends it as one of the measures of health status to assess equity in health [26]. Besides being an important cause of under-five mortality [27, 28], childhood malnutrition may adversely affect a child's intellectual development and consequently, health and productivity in later life [29, 30]. Wealth-related inequities in stunting (chronic malnutrition) and underweight in favour of the top wealth quintile clearly demonstrate the well-established link with socio-economic deprivation [31]. Hence, addressing inequities in stunting and underweight will entail initiating and implementing a multi-sectoral action and tackling the broader social determinants of malnutrition in line with the recommendations of the WHO Commission on Social Determinants of Health [32].

The overall prevalence of anaemia among under-five children is consistent of settings where malaria is endemic [33]. Anaemia affects the poorest of society disproportionately [22]. This is attested to by the finding of this study of the existence of inequities in anaemia prevalence in favour of children from wealthier segment of society. This inequity will adversely affect progress towards MDG 4, as anaemia is associated with an increased risk of child mortality [22].

The wealth-related gradient in childhood diarrhoea that is to the disadvantage of children from the poorest wealth quintile is not surprising. diarrhoea is the second main cause of death among children under-five globally [34]. It is therefore a priority to control diarrhoea in children in Ghana in order to accelerate progress towards the MDG 4 target.

Inequities in health outcomes (including diarrhoea) that are to the disadvantage of the poorest children result from increase exposure to disease risk factors; low coverage of preventive interventions and limited access to curative services [12, 35]. These problems require interventions both within and outside the health sector that the stewards of health in Ghana have to address simultaneously in order to expedite progress towards the MDGs in a sustainable manner.

The BMI indicator suggests the co-existence of overweight and obesity on the one hand and underweight on the other among women 15-49 years of age. While there are inequities in favour of the rich in the prevalence of underweight (thin), overweight and obesity manifest inequities in the opposite direction - to the advantage of the poor. Underweight significantly decreases in the wealthiest quintile of the population compared to those in the bottom 20%. However, overweight and obesity increase in the wealthiest quintile compared to the poorest 20%. Ghana, like other developing countries may be experiencing the double burden of malnutrition. Abnormal BMI has an adverse effect on pregnancy outcomes [36] and is likely to impede progress towards achieving the MDGs on maternal and child health. It is therefore essential to put appropriate measures that help women to maintain normal BMI.

Anaemia among women likewise manifests pro-wealthy inequities. However, it should be noted that even among the wealthiest quintile, the rate is in the range that is labeled as severe public health problem. Anaemia poses an increased risk for maternal and child mortality [22] and is likely to directly thwart efforts to achieving the MDGs 4 and 5 targets. Although the poorest have to be targeted with preventive and curative interventions, given the magnitude of the problem, it is vital to also implement measures aimed at universal coverage with interventions against anaemia.

The results indicate that the following interventions do not manifest wealth-related gradients: treatment of diarrhoea in children, childhood vaccines, sleeping under ITN (child and pregnant woman). Skilled attendance at birth, place of delivery (health facility, public health facility, private health facility) and Caesarean delivery increase significantly among the wealthiest compared to the poor. It is interesting to note that even the publicly-funded child delivery services are used more by the rich than the poor, reinforcing the assertion that government health spending in Africa benefits the richest of society more than the poorest [37]. It is evident that access of the poor to emergency obstetric care services has to be increased in order to improve maternal health conditions. However, this should not only be limited to increase in the supply of emergency obstetric care. Demand side factors (e.g. individual, household and community level characteristics) should also be examined in order to address any obstacles to utilizing these services by the poorest women.

Not unexpectedly, home delivery significantly decreases as we move from the poorest wealth quintile to the highest. There is an urgent need to reverse this situation so that more women from the poorest of society will give birth at health facilities under the supervision of skilled birth attendants. This will go a long way in bridging inequities and accelerating the progress towards achieving the maternal mortality reduction target of MDG 5.

The fact that intermittent preventive treatment for malaria during pregnancy has a pro-rich inequity may possibly raise a question about the responsiveness of the health system. For example, the Ghana DHS 2008 shows that while 80% of women in the wealthiest quintile are informed of signs of complications of pregnancy, only 55% of those in the poorest quintile are provided with the same information. Thus, socio-economic status seems to affect the quality of care provided to pregnant women.

In summary, pro-rich inequities in most of the maternal and child health interventions in Ghana are wide spread and need to be addressed vigorously in order to improve the health conditions of the poorest women and children and expedite progress towards achieving the MDGs related to maternal and child health in the few years left to the target date of the MDGs.