title: Growing inequities in maternal health in South Africa: a comparison of serial national household surveys.
abstract: Rates of maternal mortality and morbidity vary markedly, both between and within countries. Documenting these variations, in a very unequal society like South Africa, provides useful information to direct initiatives to improve services. The study describes inequalities over time in access to maternal health services in South Africa, and identifies differences in maternal health outcomes between population groups and across geographical areas.
  
  
  
  Data were analysed from serial population-level household surveys that applied multistage-stratified sampling. Access to maternal health services and health outcomes in 2008 (n = 1121) were compared with those in 2012 (n = 1648). Differences between socio-economic quartiles were quantified using the relative (RII) and slope (SII) index of inequality, based on survey weights.
  
  
  
  High levels of inequalities were noted in most measures of service access in both 2008 and 2012. Inequalities between socio-economic quartiles worsened over time in antenatal clinic attendance, with overall coverage falling from 97.0 to 90.2 %. Nationally, skilled birth attendance remained about 95 %, with persistent high inequalities (SII = 0.11, RII = 1.12 in 2012). In 2012, having a doctor present at childbirth was higher than in 2008 (34.4 % versus 27.8 %), but inequalities worsened. Countrywide, levels of planned pregnancy declined from 44.6 % in 2008 to 34.7 % in 2012. The RII and SII rose over this period and in 2012, only 22.4 % of the poorest quartile had a planned pregnancy. HIV testing increased substantially by 2012, though remains low in groups with a high HIV prevalence, such as women in rural formal areas, and from Gauteng and Mpumalanga provinces. Marked deficiencies in service access were noted in the Eastern Cape ad North West provinces.
  
  
  
  Though some population-level improvements occurred in access to services, inequalities generally worsened. Low levels of planned pregnancy, antenatal clinic access and having a doctor present at childbirth among poor women are of most concern. Policy makers should carefully balance efforts to increase service access nationally, against the need for programs targeting underserved populations.
authors: Epidemiology and Strategic Information Unit, Human Sciences Research Council, Pretoria, South Africa. nwabiri@hsrc.ac.za.
authors: Njeri
authors: 0000-0002-7436-3504
authors: N
authors: Wabiri
authors: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Matthew
authors: M
authors: Chersich
authors: Evidence Based Solutions, Cape Town, South Africa.|Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
authors: Olive
authors: O
authors: Shisana
authors: Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Duane
authors: D
authors: Blaauw
authors: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Helen
authors: H
authors: Rees
authors: Epidemiology and Strategic Information Unit, Human Sciences Research Council, Pretoria, South Africa.
authors: Ntabozuko
authors: N
authors: Dwane
mesh_terms: D000293:Adolescent; D000328:Adult; D005191:Family Characteristics; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D000068097:Maternal Health / Q000706:statistics & numerical data*; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D011247:Pregnancy; D012959:Socioeconomic Factors; D013019:South Africa; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Access; Equity gap; Maternal health; National household survey; Relative inequalities; South Africa