Associations of acute conflict with equity in maternal healthcare: an uncontrolled before-and-after analysis of Egypt demographic and health survey data

Equitable access to and usage of appropriate and good-quality maternal care is a key challenge in addressing maternal and neonatal health in low and middle-income countries (LMICs), including conflict-affected settings [1]. Improving health equity includes removing unfair and avoidable differences in healthcare access and usage among populations, e.g. those based on socioeconomic, demographic, or geographical status [2–4]. Nearly 60% of global maternal deaths occur in conflict-affected LMICs [1, 5], with a maternal mortality ratio of 417 per 100,000 live births in 2014 [1]. In the same year, skilled birth attendance (SBA) was 85% higher among the richest women in LMICs, while the chances of four or more antenatal care visits were 25% higher among highest educated women [6]. A study conducted in 19 conflict-affected LMICs reported that mean access to SBA among the lowest socioeconomic quintile was 12.2% compared to 81.2% among the richest quintile [2]. The United Nations’ (UN) Sustainable Development Goal agenda recommends reducing inequities in maternal care access in conflict-affected LMICs to improve maternal health [5]. However, evidence is limited on maternal care-seeking patterns and how conflict affects equity in access to or usage of maternal healthcare in LMICs.

Health equity is a complex concept to define and measure, particularly in conflict-affected settings [2, 7, 8]. It can be categorised as horizontal or vertical [2, 7, 8]. Horizontal equity determines that women with the same health needs are treated equally, irrespective of morally irrelevant factors (e.g. age, ethnicity, income, autonomy, ability to benefit etc.) [2, 7, 8]. For example, women from the same socioeconomic background are treated equally by caregivers without any discrimination [2, 7, 8]. Vertical equity determines that women with differing health needs are prioritized differently, according to morally irrelevant factors (e.g. age, autonomy, ability to benefit, income etc.) [2, 7, 8]. These differing health needs are based on their current status of social determinants. For example, poor women might receive more government support than rich women due to relatively higher economic vulnerability [7, 8].

The Egyptian healthcare system was identified as one with increasing inequities in the social determinants of maternal care and services availability, access, and usage [9]. It was thus relevant to assess how women with unequal endowments of social determinants (e.g. wealth) used maternal services during the acute 2011–2012 conflict. Literature and policy evidence, from LMICs and resource-constrained settings, indicates that vertical equity should be addressed prior to horizontal equity [10, 11]. Unless disadvantaged groups are given differential treatment, prevailing gaps in health status will not be reduced substantially [10, 11]. Thus, this study focused where possible on vertical equity in usage of maternal care services during the acute Egyptian conflict.

Evidence from conflict-affected countries shows that conflicts adversely affect population health and maternal care by restricting timely availability and access to quality care [12–14]. Addressing equity in maternal care is challenging in conflict-affected settings, particularly during acute conflict [4, 15–17]. Conflict and violence can reduce health system capacity for equitable health service delivery [4, 16]. Social determinants of health may function less predictably during conflict [3], e.g. violence may prevent facility access even if financial barriers are removed [18, 19]. Lack of reliable data on maternal care use and equity patterns during conflict limits health system preparedness to support women during conflicts [15, 17]. In this context, this study tested the association between the acute 2011–2012 Egyptian conflict and maternal care usage among different socioeconomic, demographic, and geographic groups.

Egypt was chosen as a case study because the 2014 DHS provided one of the only robust datasets that enabled a before-and-after comparison of the association of conflict with equity of maternal care usage. Evidence was limited on the 2011–2012 Egyptian conflict’s effect on maternal care in general and equity dimensions in particular [20]. Egypt is considered at risk of further conflict, yet despite health system reforms in the last decade, policy attention to building resilience to conflict has been limited [21, 22]. A better understanding of the socioeconomic determinants of maternal care could help inform policy in addressing equity during future conflicts [21]. Additionally, maternal care in Egypt has become increasingly inequitable in the past decade [22, 23]. For example, a recent study reported that a one unit increase in the mean socio-cultural resourcefulness score was associated with 1.55 higher odds of using any antenatal care (ANC) and 1.31 higher odds of institutional delivery [9]. Rural areas have a relatively lower percentage (20%) of the total health centres nationally [23–25]. How predictable social determinants of maternal care are during acute conflict and whether maternal care use changes differently during conflict among different socioeconomic groups are also not that known in the Egyptian context.

This study aimed to assess the association between the 2011–2012 Egyptian conflict and usage of maternal services among women in different socioeconomic, demographic and geographic groups in order to examine vertical equity. Objectives were to compare usage of antenatal, delivery, and postnatal services before and during the conflict, by: (i) maternal age; (ii) residence; (iii) education; (iv) employment; and (v) household wealth.

The association between the acute conflict and equity in maternal services usage generally appeared equitable, challenging prevailing assumptions in the literature [42]. A comparison of study findings with those from the 2014 EDHS report, which examined maternal care use over a longer period (2009–2014), helps interpretation of study associations within broader socioeconomic trends. Patterns of equity in maternal care usage during the conflict differed from recent trends in Egypt, indicating vertical equity did not worsen and in some cases improved for specific vulnerable groups during conflict. For example, while associations between conflict and maternal care among socioeconomically advantaged women were minimal, known vulnerable groups (e.g. rural women) had a higher odds of getting maternal care in conflict than pre-conflict. Thus, this study found a relative improvement in vertical equity, as socioeconomically disadvantaged groups such as rural and low-income women had a relatively higher chance of accessing maternal care during conflict (relative to pre-conflict) than their better-off counterparts. However, conflict did not noticeably worsen the chance of maternal care access among socioeconomically advantaged women during the conflict compared to the pre-conflict period.

Recent trends in Egypt indicated higher maternal care use among richer women, while evidence elsewhere indicated that maternal care for both rich and poor women can be adversely affected during conflicts [20]. However, compared with pre-conflict, the odds of receiving maternal care during conflict increased for both poorer and richer women. Unlike recent trends in Egypt, the odds of maternal care increased during conflict as maternal age increased. Research from Nepal, Sri Lanka and Yemen indicated a negative association of conflict with age, while Iraq reported lower use of SBA (22%) among women under 25 [14, 43–49]. Also contrary to recent trends in Egypt, and evidence elsewhere, odds of maternal care use during conflict did not increase with increased educational attainment [2, 21]. Against recent trends, rural women had relatively higher odds of using maternal services during conflict, while evidence elsewhere shows conflict could impact both rural and urban women adversely [29, 42]. Reinforcing recent trends in Egypt, and existing evidence from LMICs, employed mothers had increased odds of maternal service use during conflict [17, 21, 42]. However, the odds of physician-assisted delivery during conflict also increased for unemployed mothers.

Age-related findings were comparable with those from the 2014 DHS report. Both reported that women aged 30–34 were more likely to deliver in public institutions [21]. Evidence suggests that public providers are more frequently chosen by older, poorer, and more rural residents in Asia [11], mainly due to trust in provider behaviour, affordability, and availability in rural areas [4, 50]. Another study in Egypt also indicated a higher reliance on public sector childbirth among women above age 30 [51, 52]. Additionally, the fertility rate in Egypt is somewhat higher among older women living in rural areas, where public-sector facilities are more readily available [9, 15, 23].

This study found lower odds of any PNC visits for women aged 25–29 than for older women during conflict compared to pre-conflict, while recent country trends indicated comparatively higher PNC use in this age group. PNC attendance is typically higher among women who deliver in private institutions in LMICs, particularly in Egypt [15, 53]. An assessment of maternal care in conflict-affected settings indicated that women’s usage depended on perceived need and ability to access care without endangering life [5, 54]. Other studies indicated women may have wanted to reach home safely rather than wait for PNC during conflict [1, 55, 56].

In Egypt, urban areas report better physical access to health centres [23, 25] and fewer socioeconomic and cultural barriers than rural areas [9]. Despite this, rural women had higher odds of using maternal services during the conflict (relative to pre-conflict) than urban women, possibly reinforcing media reports that conflict was more severe in urban areas [30]. The existing literature is inconclusive as to how the severity of conflict affects maternal care. Evidence from acute conflict-affected Nepal, Morocco and Afghanistan indicates that it was not the severity of conflict but rather availability of services that determined maternal usage [43, 55, 57]. Conversely, evidence from 19 conflict-affected sub-Saharan African countries and Sri Lanka indicated that maternal care was more adversely affected in urban areas during severe conflict [12, 14].

Contrary to existing literature in LMICs, including the 2014 DHS report, the odds of maternal care use (i.e. ANC, SBA, or public sector delivery) did not decrease among less-educated women compared with pre-conflict [43, 48, 58, 59]. Pooled odds ratios from a systematic review showed that education level was associated with 20% higher odds of SBA usage during conflicts in Asia and the Middle-East [60]. However, literature also indicates that availability of service and social cohesion can be more relevant during conflict than women’s education status [61]. As the Egyptian conflict was less severe, its potential adverse effect on less educated women could have been very limited.

Qualitative evidence from Egypt and similar settings indicated that some socio-cultural barriers to maternal care that are more frequently experienced by less-educated women can be stronger during conflict [20, 48]. For example, the literature indicates that less-educated women in Asia have relatively weak autonomy in decision-making, travel, and purchasing power, especially during conflict [61, 62]. Thus, compared to more-educated women, they tend to use public rather than more expensive private facilities. However, in this study context, this use of public sector among less educated women could be more of a reflection of the recent trends in the country.

Similar to the 2014 DHS report and a study from Yemen, employed women had relatively higher odds than unemployed women of using SBA and physician-assisted delivery during conflict [21, 46]. However, unlike the DHS report, this study did not find significantly greater ANC and PNC use among employed women during conflict compared to pre-conflict. The higher odds of physician-assisted delivery suggested employed women had more access to private institutional care during conflict. Another study from Egypt reported working women were more likely to use maternal care and physician-assisted delivery from private institutions irrespective of conflict [9, 63]. However, a slight increase in the odds of physician-assisted delivery among unemployed women during the conflict compared with pre-conflict is worth noting. Given the perceived complications in delivery care, women may have felt relatively safer using physician services than those of other types of providers during the conflict [42]. Alternatively, the extensive policy attention on quality of maternal care could have prompted them to seek physician services [64]. This finding could be also a reflection of the recent trends in the country, as Egypt in general depends largely on private sector and physicians for maternal care [21].

Unlike the 2014 DHS report and other studies in Egypt, women from poor households had higher odds of using maternal care during conflict (relative to pre-conflict) than women from wealthy households, possibly reinforcing the role of conflict in driving maternal care beyond the level of affordability [11, 20, 21]. This finding supported the literature, which indicates that the effect of household wealth on maternal services use during conflict is unpredictable, due to emergency nature of maternal care and households’ perceived need for care [2]. Pooled odds ratios from a systematic review showed that household wealth was not associated with increased odds of SBA usage during conflicts in Asia and the Middle-East [60]. In Egypt, poor women are more concentrated in rural areas, while conflict was also less severe in rural areas, possibly supporting this higher use among poor women [20]. However, the literature does indicate that women accessing care irrespective of their financial status is regressive, especially in an inequitable health care system [2, 4]. Although poor women used services, given the regressive health financing system and inadequacy of supplies in public hospitals, there could have been a higher chance of financial catastrophe, which was not assessable [1, 3, 19].

Despite limitations, this study is a rare attempt to measure the association between an acute conflict and equity of maternal services usage. Maternal care use during conflict was generally vertically equitable in Egypt, as opposed to prevailing evidence in LMICs. Authors call for specific equity strategies in maternal policy to help address the unpredictable effects of conflict on equity of health services provision, such as those for maternal care examined here. Additional evidence is needed on how conflict affects out-of-pocket expenditure, financial catastrophe, and quality of maternal care among women from different socioeconomic groups.