Beyond Geographic Boundaries: Disentangling Individual, Household, and Health Systems Determinants of Urban-Rural Disparities in Maternal Health Care Utilization in Ghana
1
Dental School, University of Ghana, Accra, Ghana
2
Obstetrics and Gynaecology, Korle Bu Teaching Hospital, Accra, Ghana
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Urban-rural disparities in maternal health care utilization throughout sub-Saharan Africa require investigation to determine whether they represent inherent residence effects or compositional differences in population characteristics. Understanding these underlying mechanisms is essential for developing appropriately targeted policy interventions.
METHODS:
This study analyzed 9,353 births from the 2022 Ghana Demographic and Health Survey using survey-weighted logistic regression with sequential adjustment for individual, household, and contextual factors. We examined associations between urban-rural residence and maternal care outcomes: antenatal care frequency, facility-based delivery, and skilled birth attendance. Multilevel modeling estimated community-level clustering; concentration indices quantified wealth-related inequality within geographic strata.
RESULTS:
Antenatal care initiation was nearly universal (rural 97.7%, urban 98.6%), but considerable disparities existed in visit frequency. Among rural women, 85.4% achieved four or more visits compared to 91.6% urban (6.2 percentage point difference, 95% CI 3.8-8.6). Facility delivery reached 98.7% rurally and 99.6% urban. Unadjusted analyses showed urban residence associated with 1.86 times higher odds of adequate antenatal visits (95% CI 1.42-2.44, p<0.001). However, following adjustment for maternal education, household wealth, health insurance, maternal age, birth order, and region, urban advantage disappeared (adjusted OR 1.01, 95% CI 0.69-1.49, p=0.942). Health insurance emerged as the predominant predictor; uninsured women faced 74% reduced odds of adequate care (OR 0.26, 95% CI 0.17-0.39, p<0.001). This effect proved particularly dramatic rurally, where insurance distinguished 87.4% utilization among insured from 54.6% among uninsured women. Multilevel analysis demonstrated substantial community-level clustering (intraclass correlation coefficients: 0.26 for antenatal frequency, 0.86 for facility delivery).
CONCLUSIONS:
Urban-rural disparities in Ghana's maternal care utilization reflect compositional differences in education, wealth, and insurance coverage rather than residence itself. Insurance coverage's disproportionate rural impact identifies a crucial policy intervention point, while substantial unexplained community-level variation indicates important unmeasured health systems factors requiring further investigation.
Urban-rural disparities in maternal health care utilization throughout sub-Saharan Africa require investigation to determine whether they represent inherent residence effects or compositional differences in population characteristics. Understanding these underlying mechanisms is essential for developing appropriately targeted policy interventions.
METHODS:
This study analyzed 9,353 births from the 2022 Ghana Demographic and Health Survey using survey-weighted logistic regression with sequential adjustment for individual, household, and contextual factors. We examined associations between urban-rural residence and maternal care outcomes: antenatal care frequency, facility-based delivery, and skilled birth attendance. Multilevel modeling estimated community-level clustering; concentration indices quantified wealth-related inequality within geographic strata.
RESULTS:
Antenatal care initiation was nearly universal (rural 97.7%, urban 98.6%), but considerable disparities existed in visit frequency. Among rural women, 85.4% achieved four or more visits compared to 91.6% urban (6.2 percentage point difference, 95% CI 3.8-8.6). Facility delivery reached 98.7% rurally and 99.6% urban. Unadjusted analyses showed urban residence associated with 1.86 times higher odds of adequate antenatal visits (95% CI 1.42-2.44, p<0.001). However, following adjustment for maternal education, household wealth, health insurance, maternal age, birth order, and region, urban advantage disappeared (adjusted OR 1.01, 95% CI 0.69-1.49, p=0.942). Health insurance emerged as the predominant predictor; uninsured women faced 74% reduced odds of adequate care (OR 0.26, 95% CI 0.17-0.39, p<0.001). This effect proved particularly dramatic rurally, where insurance distinguished 87.4% utilization among insured from 54.6% among uninsured women. Multilevel analysis demonstrated substantial community-level clustering (intraclass correlation coefficients: 0.26 for antenatal frequency, 0.86 for facility delivery).
CONCLUSIONS:
Urban-rural disparities in Ghana's maternal care utilization reflect compositional differences in education, wealth, and insurance coverage rather than residence itself. Insurance coverage's disproportionate rural impact identifies a crucial policy intervention point, while substantial unexplained community-level variation indicates important unmeasured health systems factors requiring further investigation.
| eISSN: | 2654-1459 |
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