Assessing the joint effects of education, economic status, empowerment, and employment (4Es) disparities on the co-coverage of maternal, newborn and child health care services in sub-Saharan Africa: an application of the intersectionality approach.

Background: Although education, employment, economic status, and empowerment (4Es) are known to individually influence inequalities in maternal, newborn, and child health (MNCH), their combined effects have not been thoroughly studied in sub-Saharan Africa (SSA). We applied an intersectional approach to understand the joint effect of the 4Es on MNCH co-coverage in different settings in SSA. Methods: We used 25 Demographic and Health Survey data sets and employed a multilevel analysis of individual heterogeneity and discriminatory accuracy to assess the intersectional effects of the 4Es on MNCH service co-coverage and inequalities within and across countries. The variance partition coefficient and proportional change in variance (PCV) statistics were applied to quantify total intersectional effects. Results: Among 103 388 women with children aged 12-59 months, 4.6% of the variance in co-coverage of ≥6 MNCH interventions (co-coverage ≥6) occurred at the intersectional strata level. Most of this variance (90.3%) was due to the additive effects of the 4Es, with education (PCV partial = 80.7%) the primary contributor, followed by economic status (PCV partial = 9.8%). The lowest co-coverage was observed among women with no education, unemployment, low economic status, and low empowerment. Inequalities were more pronounced in countries with lower universal health coverage (UHC) indices, where co-coverage ranged from 17.5% (95% confidence interval (CI) = 14.6-21.1) to 67.0% (95% CI = 62.9-70.8), compared with 42.8% (95% CI = 38.0-47.8) to 68.5% (95% CI = 64.7-71.8) in countries with higher UHC indices. Evidence of multiplicative effects was also observed. Services with a high disparity included skilled birth attendance, antenatal care, and access to improved water sources. Country-specific analysis revealed that 11 countries showed very low heterogeneity (<5%) in the co-coverage of ≥6 interventions. Conclusions: This is the first study to explore how the 4Es jointly affect MNCH co-coverage in SSA. The results reveal that these 4Es are connected and affect MNCH co-coverage, particularly in key services, including skilled birth attendance, antenatal care, and access to improved water sources. The most privileged groups had significant protective effects, whereas those with fewer societal privileges showed minor effects. Learning from countries with low disparities in service co-coverage can help reduce the gaps in other countries.