Effective coverage cascade of the maternal healthcare continuum in Cameroon: An analysis of inequalities from service contact to quality-adjusted coverage

Abstract

Background: The progressive increase in maternal health (MH) coverage observed in Cameroon over the past decades has not been accompanied by a satisfactory reduction in maternal mortality. In this study, we analysed inequalities in service contact, intervention care and quality-adjusted coverage of maternal healthcare continuum in order to assess the capacity of the health system to provide comprehensive and equitable care. Methods: We combined data from the 2018 Cameroon Demographic and Health Survey and the 2015 Emergency Obstetric and Neonatal Care Evaluation Survey of Health Facilities to estimate the quality-adjusted coverage of antenatal care and intra- and postpartum care. Inequalities were assessed using absolute and relative inequality measures. Results: Contact coverage for antenatal care services was 86.3% (95% CI: 85.4-87.1), but only 14.4% (95% CI: 13.7-15.1) of women had the opportunity to receive comprehensive antenatal care of optimal quality. Similarly, contact coverage for intra- and postpartum care was 68.5% (95% CI: 67.3-69.6), but only 31.4% (95% CI: 19.6-26.4) of women had the opportunity to receive optimal quality intra- and postpartum care. The missed opportunity for health benefits was greater for intra- and postpartum care than for antenatal care (20.0% vs. 10.9%). There are large inequalities in the quality-adjusted coverage of the continuum of maternal healthcare by region, place of residence, religion, level of education and wealth quintile index. Relative inequalities are accentuated when the quality of MH services is taken into account. Although all categories of women are affected by the loss of opportunities for health benefits, it is the most advantaged socioeconomic groups who are most affected. Conclusion: Our results highlight the importance of using effective coverage indicators specific to maternal health care, and of combining measures of relative and absolute inequalities to establish priorities and propose recommendations to policy-makers adapted to the context of low- and middle-income countries.