The association between the acute conflict and equity in maternal services usage generally appeared equitable, challenging prevailing assumptions in the literature . 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 . 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, 43,44,45,46,47,48,49]. 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 . Evidence suggests that public providers are more frequently chosen by older, poorer, and more rural residents in Asia , 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 . 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 . 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 . However, literature also indicates that availability of service and social cohesion can be more relevant during conflict than women’s education status . 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 . Alternatively, the extensive policy attention on quality of maternal care could have prompted them to seek physician services . 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 .
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 . 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 . 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 . 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].
Policy and research implications
Study findings show that existing equity patterns in maternal care changed unpredictably during the conflict. If the healthcare delivery system is well developed with progressive health financing, the scope for a conflict to cause large inequities is limited. However, given the limited availability of quality maternal care, inequities in service delivery, and regressive health financing in Egypt, maternal policy could benefit from specific in-built equity strategies to address unpredictable effects of conflict on equity [2, 4]. For example, strategic involvement of community-based groups, volunteers, and local providers has helped pregnant women during emergencies . Depending on the severity of conflict and women’s relative vulnerability, failure to implement remedial measures could worsen equity [2, 4].
Experiences in several countries affected by acute and sporadic conflicts (e.g. Nepal, Myanmar) showed that post-conflict reconstruction could offer opportunities to build more equitable health systems than existed previously [17, 61]. The commitment shown by Egyptian policy-makers in implementing multi-sectorial policy measures to address health inequities is worth acknowledging [10, 65]. Improved maternal care use among socioeconomically disadvantaged groups could be partially due to this increased policy attention. Increasing the involvement of non-state actors may strengthen the government’s equity-driven initiatives further. For instance, active participation of civil society in policy-making may inspire maternal health policies to be more equity-focused . Given the financial and technical constraints in the public health system, development partners and the private sector could leverage funding and technical capacity to implement equitable maternal care strategies . Enhancing the capacity of providers and community-based networks could reduce access barriers for previously marginalised groups .
Due to data constraints, this study did not assess the association between conflict, out-of-pocket expenditure, and financial catastrophes due to maternal care. Egypt’s proportion of out-of-pocket healthcare expenditure is high at more than 70%, while its financial risk-protection measures are still evolving . User fees and lack of pre-payment systems are known limitations in the Egyptian health system [66, 67]. During major conflicts, financial access to care typically deteriorates due to collapsing livelihoods and healthcare delivery services . Though the 2011–2012 Egyptian conflict was not particularly severe, maternal needs could have engendered financial hardship, particularly among poorer groups [27, 68,69,70].
In-depth research is needed to explore the underlying drivers of maternal care equity during future conflicts . It should be noted that socioeconomic adversity in Egypt is more concentrated in the Rural South Region, which was relatively less conflict-affected than the more affluent urban areas [11, 20]. This could be a reason for maternal care among vulnerable groups not being more significantly adversely affected by conflict in this study. Egypt has recently been implementing several maternal and child health initiatives in the Rural South Region , which could have positively influenced maternal care among socioeconomically disadvantaged groups. Additional evidence is needed on the differential association of conflict and quality of maternal care used by different groups. Assessing the equity dimension in quality of maternal care would help understanding of conflict’s potential effect on maternal health status among different groups . The literature indicates that LMICs generally provide relatively low-quality maternal services to economically poorer women, as is reportedly the case in Egypt [70, 72].
Several potential limitations relate to the nature of the data. First, as DHS data were not specifically collected to assess the effects of conflict, customising data led to omitting relevant ANC and PNC variables due to incompatibility with a before-and-after analysis. Second, DHS data were self-reported and described details of maternal care-seeking in previous years, possibly leading to recall or social desirability biases . However, a validation study in LMICs found moderate to high sensitivity and moderate validity for self-reported coverage of maternal care in surveys [74, 75]. DHS data were representative of childbirth experiences in the general population, and DHS employed standardised procedures to ensure data quality and tools were rigorously tested across time. Third, the EDHS wealth index is potentially biased against rural households, by including more items or utilities (e.g. electrical appliances) suited to urban populations . Fourth, underlying temporal trends could have influenced the measurement of effect size, though the period under consideration was too short for a large temporal trend to have occurred . Fifth, as the effect size found was relatively small, qualitative exploration would have been helpful to generate additional explanatory evidence. Sixth, given the country-wide geographical spread of the conflict and lack of data on region-specific exposures, this study considered all women to be equally exposed to conflict and could not differentiate level of exposure. Finally, the number of outcomes and potential effect modifiers considered meant that multiple statistical tests were performed, increasing the likelihood of finding evidence of effect modification by chance alone.