Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

Introduction Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.Methods Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity >= 5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.Results This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.Discussion Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.